Fillable Financial hardship form (Rochdale Metropolitan Borough Council)

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Financial hardship form (Rochdale Metropolitan Borough Council)

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Financial hardship form
Adult Care Services
In line with our Charging Policy you can appeal against the charges on the grounds that paying the
amount you owe will cause you financial hardship.
If you want to do this you should fill in the attached form and send it back to:
Adult Care
PO Box 100
Rochdale Borough Council
OL16 9NP
We will continue to send you invoices for the amount you have to pay and if we are taking any recovery
action this will continue.
When we have received your form we will consider your request and write to you with our decision.
Data Protection
Find out how we use your personal information at - http://www.rochdale.gov.uk/privacy
THIS PAGE IS BLANK
Appeal against Adult Care Charges
Name:
Reference:
Address:
Section One: Earnings
If neither you or your partner are working please go to Section Two
Are you working?
Who are you employed by
(if you have more than one
job please tell us about
them all)
How often do you get paid?
How much do you get paid
after Income Tax and
National Insurance?
If you are off sick please
tell us:
You
Yes
every
week
every
four
weeks
£
The date you
last worked
The date you
expect to go
back to work
No
every two
weeks
every
month
Yes
No
every
week
every two weeks
every
four
every month
weeks
£
The date you
last worked
The date you
expect to go
back to work
Section Two : Your other income
If you get state benefits or pensions please tell us:
Your National Insurance
number
Your date of birth
Please tell us what state benefits or pensions you get.
Benefit or pension
Job Seeker’s Allowance or Income
Support
Universal Credit
Employment Support Allowance or
Incapacity Benefit
Personal Independence Payments
Disability Living Allowance or
Attendance Allowance
Every week
How much you get and who gets it
Every four
Every month
You
weeks
Your
partner
Tax Credits
Child Benefit
Retirement Pension
Any other benefit
you get (please
tell us what it is
and how much it
is).
Please tell us about any other
income you get.
How much you get and who gets it
Every week
Every four
weeks
Every month
You
Your
partner
Works pension (or
superannuation)
Maintenance
Money from other people who live
with you, for example a grown up
son or daughter or a lodger.
Any other income
you get (please tell
us what it is)
Section Three: Money in the bank and other savings
Please tell us about any money you and your partner have in the bank, building society, Post Office
and any other savings and investments.
Type of savings
Account balance
Type of savings
Account balance
Bank account
Building society
Savings account
Post Office
Other
Please give details
Section Four: What you pay out
Please tell us about anyone who is financially dependent on you (if you have dependent children
please tell us their age):
Please tell us about your household bills
Expense
How much you pay
Every week
Every four weeks
Every month
Rent or mortgage
Council Tax
Gas
Electric
Water charges
Loans
Credit or store card payments
House insurance
Housekeeping (food, toiletries and so on)
Clothing and shoes
TV licence
TV package (for example Sky, Virgin)
Internet
Phone
Car expenses
Bus or taxi fares
School meals
Meals at work
Child care costs
Any other bills you
pay (please tell us
what these are).
Section Five: Other money you owe
Please tell us about any other money you owe to Rochdale Council, for example Council Tax
What you owe the
money for
The reference
number
How much you pay
Every week
Every four weeks
Every month
Please tell us about any other money you owe
What you owe the
money for
The amount you
owe
What payments are due
Every week
Every four weeks
Every month
Mortgage arrears
Rent arrears
Fuel arrears (gas
and electric)
Loans
Credit Card
Credit Card
Store Card
Store Card
Anything else
Section Six: Please tell us why you can’t pay the amount you owe.
Signature
Date
Full name
Phone number
You don’t have to give us your phone number but it may help us if we need to contact you again.
Send this form to:
Adult Care
PO Box 100
Rochdale Borough Council
OL16 9NP
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Financial hardship form (Rochdale Metropolitan Borough Council)

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Completed 10 December 2020

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