Fill - Free fillable Financial Assessment Form 2020-21 (London Borough of Wandsworth) PDF form

Financial

Assessment

Form

For people receiving care and

support in a residential or

nursing home (Residential Care)

or at home (Non-Residential Care)

2020-21

Why do I need to fill in this form?

Most people have to pay something towards the cost of their care and support. What you pay will depend on

your individual circumstances and the kind of care and support you need, who provides it and how often you

need help. Your financial assessment will help us decide if we can help pay for your care and work out how

much, if anything, you will have to pay towards the costs and identify any benefits you may be entitled to. If

you have savings over £23,250 you will have to pay for the cost of any care and support in full.

We ask that you return the completed form to us within 2 weeks for us to work out your personal

contribution and how much the council will contribute towards the cost of your care and support.

You can choose not to share your financial details with us. This will mean that you have to pay the full cost

of your care and support. We can still help arrange your care and support for you but if you have been

assessed as being able to pay the full cost of your care, there is an arrangement fee of £50 a week to

cover the Council’s costs for making these arrangements. We will always offer you information and advice to

help you choose the appropriate support to meet your needs.

If any of the following apply, then go to Section 2:

l I do not want to provide my financial details.

l I have over £23,250 in savings.

l I currently have no right to claim benefits (e.g. no recourse to public funds).

What information will I need to provide?

You will need to provide copies of all financial information detailed in this form. This is essential for us to be

able to confirm the information.

If you do not provide the information in the timescales required and/or fail to provide the supporting

documents, you may have to pay the full cost of your care and support.

Who can help with completing this form?

You may want to ask a friend or family member to help you or someone who already helps you manage your

finances. If you don’t have anyone to help you fill out this form and you cannot complete it yourself, we can

arrange for someone to come and visit you in your home at a time that is convenient for you.

If you need this form in another format, such as large print, please contact Adult Social Services

on 020 8871 7707 or email accessteam@wandsworth.gov.uk.

Your Full Name:

Financial Assessment Form

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Financial Assessment Form

Section 1: Personal information

Please tick the care service you need: Residential/Nursing Non-Residential

Title: Date of Birth:

First names: Surname:

National Insurance Number:

Do you have a spouse/partner/civil partner? Yes No

Mobile Telephone Number:

Home Telephone Number:

Email Address:

Current Address:

Postcode:

How long have you lived at this address?

If less than 5 years, please provide any previous addresses below:

Address:

Postcode:

Date occupied from: to:

Owner Rented Other (please specify):

Address:

Postcode:

Date occupied from: to:

Owner Rented Other (please specify):

Do you currently live alone? Yes No

Do you currently live with your family in their home? Yes No

If you do not live alone, please tell us who is living with you

Full Name Relationship to you Date of birth

If you have dependent children, please provide details below

Full Name Date of Birth

Person to receive your correspondence if not you

Title: Relationship to you:

First names: Surname:

Address:

Postcode: Contact telephone no:

Is the correspondent acting in the capacity of Enduring/Lasting Power of Attorney or Deputy?

Yes No Pending

(If yes, please enclose a copy of the Power of Attorney/Deputy document)

Please confirm what correspondence should be sent to this person below:-

All correspondence Invoices Financial Assessment

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Financial Assessment Form

Completion of this Financial Assessment Form

Who has completed this form?

Name:

Capacity (e.g. service user, friend, deputy etc.):

Contact Telephone Number:

Contact Email Address:

Section 2: Light Touch Financial Assessment

A light touch financial assessment is a short version of this form. This section should only be completed if

you agree that you do not wish to have a full financial assessment. You should only complete this section if

any of the following apply to you (please tick):

I do not wish to provide information about my finances and I am willing to pay the full cost for my

care and support services (please also sign the declaration below and on page 13).

My savings and/or assets (e.g. second property, land, stocks and shares etc.) are over £23,250

and I receive services in my own home.

I have no income (please specify reason below and when you expect your circumstances to change).

Declaration of non-disclosure of your finances

I confirm that by typing my name in the signature field below and returning the form to you by email, I am

agreeing to the terms detailed in the following statement:

You, or your authorised representative, must read the following statement then sign and date it:

‘I am aware that I will have to pay towards the cost of services I receive that are provided and/or bought on

my behalf. However, I do not want to provide financial details and I therefore agree to pay the full cost of

services provided on my behalf by the Council together with any administration fee as detailed in the Adult

Social Services fees and charges policy’.

Signed: Date:

If not service user state capacity (e.g. appointee, deputy)

If you have completed this section, then you do not need to complete the rest of this form, BUT you will need

to read and sign the declaration in Section 9 on page 13 before returning this form in the prepaid envelope.

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Financial Assessment Form

Section 3: Income

We require documentary proof of any income received. We will accept photocopies of documents such as

bank statements, DWP letters, private pension payslip etc.

IMPORTANT

If you are receiving residential or nursing care, the Care Act 2014 allows you to pay 50% of your

occupational pension, personal pension or retirement annuity to your spouse or civil partner and we will

disregard this from the financial assessment.

In view of this, our policy will be to automatically disregard 50% unless you ask us not to and we will

then include all your pension in the financial assessment calculation.

Type of income You: £/week Joint Income: £/week

Attendance Allowance

Constant Attendance Allowance

Disability Living Allowance (DLA) Care

DLA Mobility

Employment and Support Allowance (ESA)

Earned Income (after tax and deductions)

Incapacity Benefit

Income Support

Jobseekers Allowance

Occupational/Private Pension 1

Occupational/Private Pension 2

Occupational/Private Pension 3

Pension Guarantee Credit

Pension Savings Credit

Personal Independence Payment (PIP)

Living Component

PIP Mobility Component

Rental Income from Property

Severe Disablement Allowance

State Retirement Pension

Universal Credit

War Pension/War Widow’s Pension

Any other income/benefits

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Financial Assessment Form

Disabled Related Expenditure

If you receive disability benefits, we will either provide you with a standard allowance of £15 per week in the

financial assessment that covers expenditure that you need to pay from your income for your disability, or

we will ask you for information about your disability related expenditure for an individual review to work out

the exact figure.

I would like an individual review of my disability related expenditure because (please tick below):

I receive higher rate attendance allowance or disability living allowance (care component)

and do not receive any care and support during the night.

I believe my weekly disability expenses are more than the standard weekly allowance of £15.

Are you claiming any benefits?

Do you have any claims for benefits that are currently being processed? Yes No

If so, what are these benefits?

Is anyone claiming Carers Allowance for caring for you (or your partner if appropriate)? Yes No

If so, please provide their details

Title: Relationship to you:

First names: Surname:

Address:

Postcode: Contact telephone no:

Are you 60 or over? Yes No

If you have not applied for Pension Credit, please do so now by telephoning the Department for Work and

Pensions on 0800 99 1234 or 0800 7310469. Please note that if you are receiving permanent care in a care

home we may automatically include pension credit when we work out your contribution and, in this scenario,

you must apply for this benefit.

Benefits Check

You may not be receiving all the benefits that you are entitled to. If you think this may be the case, then we

can arrange a benefit check for you.

I / We would like a benefit check Yes No

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Financial Assessment Form

Section 4: Savings

Please provide details of any bank or building society accounts held including any held overseas.

Bank statement copies for the last 3 months need to be provided.

Name of bank/building Sort code Account Balance Date of Joint or sole

society Number Number Balance account

Your other assets:

Please provide documentary proof of any assets.

Details Balance Date of Joint or sole

Balance account

Post Office accounts:

Stocks/shares/unit trusts/ISAs/Bonds:

National savings certificates:

Premium/savings bonds:

Overseas income or assets:

Any other capital, income or assets (e.g. Tessa/ISA):

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Financial Assessment Form

Section 5: Outgoings

If you currently have property outgoings, please tell us below what type of property it is (e.g. detached, semi-

detached, terrace, flat, B&B).

Please tell us about the expenses you have in relation to this property:

Expense Amount £ Frequency (e.g.

weekly, monthly)

Mortgage (less any housing benefit received)

Rent (less any housing benefit received)

Ground Rent

Property Service Charge

Council Tax (less any Council Tax reduction received)

Board and lodgings

Careline/Telecare/Watch

Any other property outgoings

Please only complete the following expenditure if applying for residential or nursing care:

Who normally pays your property expenses? You Your partner Both of you Other

Expense Amount £ Frequency

Fuel/heating

Property insurance Buildings

Property insurance Contents

Water charge

Other (please specify)

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Financial Assessment Form

Section 6: Property

Do you own or rent the property listed as your address in Section 1 of the form?

Own? Yes No Rent? Yes No

If you jointly own your property, please provide the full name(s) and addresses of all other joint owner(s) of

the property:

If the property is rented, please provide the full name and address of the landlord:

Please provide details of any other property, land and businesses that you own.

Details of property, land Approximate Owned by On the market

and/or businesses owned value (please state to be sold?

exact ownership)

Person appointed to dispose Name and address of solicitor

of the property if for sale

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Financial Assessment Form

Please provide details of any overseas property, land and/or businesses that you own:

Details of property, land Approximate Owned by On the market

and/or businesses owned value (please state to be sold?

exact ownership)

Do you have a beneficial interest in any property? Yes No

If yes please provide details below including details of any rental income from the property:

Please complete the following section for residential or nursing placements only.

If you have disposed of any property and/or assets, including transfer of ownership of all or part of your

property within the last five years, please give details below. You need to provide us with evidence of when

the transfer took place.

Details of property, land, businesses Sale/disposal Owned by Disposal date

owned (including any overseas) sold price £ (please state

or disposed of exact ownership)

Do you intend to sell any of your properties/assets? Yes No

If any of the property is leased to tenants, please provide details of the rental income and the frequency of

payments you receive: £ Frequency

Termination of your tenancy (if you rent a property) Date:

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Financial Assessment Form

Section 7: Gifts and any other information

If you have made gifts worth more than £3000 per year to individuals (e.g. relatives or friends) in the last

seven years, please provide details below. Please also provide any other information which you think may be

relevant to your financial assessment.

Section 8: Protecting your Personal Information

We have a duty to support and care for those most in need. To do this, we must hold records about you,

your personal circumstances and the services/care you are receiving or may need to receive in the future.

We keep this information securely, either on paper or on an electronic record.

We manage, maintain and protect all information according to legislation, our policies and best practices.

We have security measures in place to maintain and safeguard the confidentiality, reliability and availability

of our systems and data. All information is stored, processed and communicated in a secure manner and

made available only to authorised members of staff on a need to know basis. Only the minimum amount of

information required will be shared.

We know how important it is to protect your privacy and work within the terms of the General Data

Protection Regulations (GDPR). We will safeguard your information and, in most circumstances, will not

disclose personal data without consent. However, there are some circumstances where we are allowed by

law to use certain personal information without permission.

If you would like to see the information we hold about you, you have the right to access your personal

information under GDPR. This is commonly referred to as a subject access request. You can make a subject

access request verbally, in writing or online at www.wandsworth.gov.uk

Please note you will have to provide adequate proof of identification before we can share a copy of your

record.

For more information about our Privacy Notice, please see our website at www.wandsworth.gov.uk.

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Financial Assessment Form

Section 9: Declaration and Authorisation to Share Information

I am aware that I will have to pay an assessed contribution towards the cost of services provided to me or

brokered on my behalf. I understand that the detailed figure, including the method of calculation, will be

notified to me separately. I understand that legal action may be taken against me to recover any unpaid

invoices.

I authorise the Council to obtain the details of my financial affairs that are necessary to calculate my

contribution towards services provided or brokered by the Council. I hereby agree that enquiries may be

made to my solicitor, bank manager(s) or executors concerning my financial resources.

I agree that you can undertake any financial checks that you consider necessary when reviewing this

financial assessment form.

I understand and agree to the following:

l I agree to help the Council to maximise my income by applying for all available state benefits to which I

am entitled, including Pension Guarantee Credit and/or Pension Savings Credit.

l If I supply information that is incorrect or incomplete, the Council may act against me. This will include

charging the full cost of services that the Council provides, charging an administration fee and could

include Court action.

l If I fail to declare assets that I hold either fully or part of an interest in then the Council may act

retrospectively to recover any sums due and/or may take legal action.

l The Council will use the information I have provided to calculate my contribution and may check some of

the information with other sources as allowed by the law.

l The Council can use any of the information I have provided in connection with this and any other claim for

state benefits that I have made or may make. It may give some information to other organisations, such

as Government departments, local authorities and private companies such as banks and organisations

that may lend me money, if the law allows this.

l I will inform the Council of any changes to my income and capital as soon as possible.

l I certify that the information that I have provided on this form is correct to the best of my knowledge and

belief.

l I understand that the information on this form will be processed by computer and the information

provided will be stored electronically and used in accordance with the notification made by the Council

under the terms of the Data Protection Act 2018.

l I understand that the information on this form may be disclosed to other agencies working in partnership

with the Council as specified in the registration. This may include the Department for Work and Pensions.

l I understand that all services, apart from the enablement service (which is a short-term service of up to 6

weeks of planned intensive help following an unexpected period of illness or disability and loss of

confidence) are charged from the start of the service.

l I understand that information about my financial circumstances will be reviewed annually.

l I have not deprived myself of any assets or transferred either capital or property to avoid care charges

within the last five years that have not been disclosed in the sections above. I understand that the

Council will use the provisions contained in Annex E of the Care Act 2014 Care and Support Statutory

Guidance, should any issues of deprivation of capital arise.

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Financial Assessment Form

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Financial Assessment Form

The following is only applicable to a residential or nursing permanent placement:

In acceptance of my residential/nursing home accommodation provided under the Care Act 2014, I

accept that I am required to pay towards my board charges from my income and capital. I accept and

undertake to pay my assessed contribution as it falls due. Invoices will be sent to me monthly.

I understand that the Council calculate my assessed contribution under the Care Act 2014.

I understand that if the value of my property is disregarded (not included) in my financial assessment

because my spouse or partner lives in the property as their main home, this disregard will end if their

personal circumstances change resulting in the home no longer being their main residence.

I confirm that by typing my name in the signature field below and returning the form to you by email, I am

agreeing to the terms detailed in section 9:

Signed: Date:

If not service user, please state capacity (e.g. appointee)

Section 10: Invoicing and Dispute Resolution

If we are invoicing you for your contribution, invoices will be sent to you monthly in arrears.

If you have any query regarding your invoices, or any dispute preventing payment of your debt, either you or

your representative should contact the Financial Assessments Team within 14 days from the date of the

invoice. You should provide supporting documentation and reasons for the dispute within the 14 days period.

Section 11: How to return your form

If you have received this form by email or you have downloaded it, then the form can be completed

electronically and returned to us by email. Please also scan and email any financial information such as

bank statements with the completed form. However, we will still need you to print and sign the Direct Debit

mandate and return this to us as your bank will need the original document to set this up. Please return the

completed financial assessment form and Direct Debit mandate to the Financial Assessment Team,

Wandsworth Council, PO Box 65985, London, SW18 9JS.

If you are completing this form by hand, please use the prepaid envelope to return your completed and

signed financial assessment form and Direct Debit mandate.

Section 12: Useful contacts

Benefits advice:

We work with Citizens Advice Wandsworth to make sure you get all the benefits you are entitled to.

You can contact Citizens Advice Wandsworth’s Disability and Social Care Advice Service (DASCAS) Monday

to Friday 10am to 4pm.

Phone: 0300 330 1169

Website: www.cawandsworth.org/dascas

The Financial Assessment Team can help with:

l Completing this form

l Arranging for invoices to be sent in larger print

l Any questions about the financial assessment or invoicing process.

Financial Assessment Team

Wandsworth Council

PO Box 65985

London, SW18 9JS

Phone: 020 8871 6218

Email: financeAT@wandsworth.gov.uk

For general enquiries about your care and support, please contact Adult Social Care

on 020 8871 7707 or email accessteam@wandsworth.gov.uk

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Financial Assessment Form

Direct Debit - An easier way to pay

Fed up getting bills every month?

l Wasting time queuing in banks?

l Wasting money on stamps and envelopes?

Why worry about it all?

l There is a way of paying that is easier for you and helps to reduce the council’s costs.

l If you have a bank or building society account you may find it easier and cheaper to pay by direct debit.

With Direct Debit...

l You do not have to remember to pay - it is all done for you.

l It is simple - no more cheques to write, no more stamps to buy, no more queuing, and once set up it

carries on from year to year without you doing anything.

How does it work?

l By completing the instruction below you are giving the council permission to collect payments from your

bank account.

l We will tell you well in advance of the amounts and the dates of payments.

l You stay in complete control and benefit from guaranteed safeguards - Please see below.

What Next?

l Please complete and return the form below to us. It’s as simple as that - we will do the rest!

•This Guarantee is offered by all banks and building societies that

accept instructions to pay Direct Debits.

•If there are any changes to the amount, date or frequency of your

Direct Debit Wandsworth Council will notify you 10 working days in

advance of your account being debited or as otherwise agreed. If you

request Wandsworth Council to collect a payment, confirmation of the

amount and date will be given to you at the time of the request.

•If an error is made in the payment of your Direct Debit by Wandsworth

Council or your Bank or Building Society you are entitled to a full

and immediate refund of the amount paid from your Bank or

Building Society.

If you receive a refund you are not entitled to, you must pay it back

when Wandsworth Council asks you to.

•You can cancel a Direct Debit at any time by simply contacting your

Bank or Building Society. Written confirmation may be required. Please

also notify us.

THE DIRECT DEBIT GUARANTEE

6 2 7 2 7 1

Instruction to your Bank or Building Society to pay by Direct Debit.

OFFICE USE ONLY:

1 Name and full postal address of your Bank or Building Society branch:

__________________

____________________________

2 Branch sort code:

3 Bank /Building Society

account number:

4 Name(s) of account holder(s):

OFFICE USE ONLY:

Instruction to your Bank or Building Society

Please pay Wandsworth Council Direct Debits from the account detailed

in this instruction subject to the safeguards assured by the Direct Debit

Guarantee. I understand that this instruction may remain with

Wandsworth Council and, if so, details will be passed electronically to

my Bank/Building Society.

Signature(s):

Date:

Service User Number

Please fill in the form using black ink and send it to:

Wandsworth Council, WBC Exchequer Services, PO BOX

4424, Shepton Mallet, Somerset, BA4 5BT

Banks and Building Societies may not accept Direct Debit instructions

for some types of account.

!

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Financial Assessment Form

For Office use only

Checklist (also see guidance) Yes/No Comment

Full cost?

Declaration signed?

Direct debit mandate enclosed?

Income – evidence provided?

Assets – evidence provided?

Bank statements for 3 months?

Benefits advice required?

Name

Signed: Date:

Designed and produced by Wandsworth Design & Print. wdp@wandsworth.gov.uk BT.2368 W (3.20)

Please return completed form to:

Financial Assessment Team

PO Box 65985

London

SW18 9JS

Fill Online, Printable, Fillable, Blank Financial Assessment Form 2020-21 (London Borough of Wandsworth) Form

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