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
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
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.
Financial Assessment Form