Claim for Council Tax Support
and Housing Benefit
Do not fill out this form until you have read these notes. After you have read and
understood them, remove the notes by tearing along the perforated line.
Do not fill in this form if you already get Council Tax Support or Housing Benefit from Somerset West
and Taunton Council and you have moved to another address within the area or found work. Instead,
complete a Return to Work or Change of Address form.
About the form, how to claim and the proof we need
We have written this form in plain English so it is easier to understand. We need you to answer in full so
we can pay you the right amount of benefit. For example, if you receive an allowance for a disability, it
could mean you get more benefit. You may not have to fill in all parts of the form but you must fill in all
the parts that apply to you.
We need to see proof of some of the things you tell us about. There is a checklist on pages 21 and 22
to help you. If you are not sure if we need to see proof of something, phone us on 0300 304 8000.
We will normally treat the day you first contacted us to send this form as the date you want to claim.
We call this day the “date of first contact”. You have one month from the “date of first contact” to give
us the completed form and all the proof we need.
We ask you to return the proof and form together, but if you do not have all the information to go with
your form, make sure you give us your claim within one month of the date of first contact.
If we get your form more than one month after the “date of first contact”, we can only pay any Council
Tax Support or Housing Benefit you may be due from the Monday after we receive it.
If we did not issue you with this form, for example you downloaded it from our website or someone
got the form for you, phone us immediately on 0300 304 8000 and tell us you are going to claim. We
will then treat the day of your call as the “date of first contact”.
We can arrange a private appointment with you to help you with your claim. If you give us the proof
and information we need, we can work out your claim immediately.
Fill in the form using black ink. If you make a mistake, cross it out and put the right answer next to it.
Do not use correction fluid or tape. Answer Yes or No questions by putting a tick in the relevant
box. If you are picking an answer from a list, tick the box that applies to you.
Make sure you read and sign the declaration on page 20 when you have filled in the form,
The sooner we get your form with all the proof we need, the sooner we can work out your claim.
Contact Information for help to claim Housing Benefit or Council Tax Support
Due to COVID-19, our offices are closed. Please do not write to us or send us your claim through the post.
Download this claim form and fill it in electronically. When you have finished, save it to your device.
The checklist tells you the evidence we need to see to assess your claim. Use a smartphone or mobile
device to take photographs of the evidence you need to support your claim. Send your completed claim
and photos of your evidence to us by email. Make sure you put your full name and address in the email.
About Housing Benefit
Housing Benefit can pay all or part of your rent. It may also help towards things you have to pay for,
like cleaning of shared areas. You must pay your rent while you wait for us to work out your benefit. If
you are having difficulties, contact your landlord immediately. We cannot help you pay deposits, rent in
advance or mortgage payments.
About Council Tax Support for people of pension age
Council Tax Support for people of pension age allows us to pay all or part of your Council Tax.
Second Adult Rebate is a form of Council Tax Support for anyone sharing their home with someone
aged over 18 who is on a low income. You can claim Second Adult Rebate if:
you are the only person in the property liable to pay Council Tax, and
there is at least one other person living with you who is not your partner, or your tenant.
If you only want to claim Second Adult Rebate, fill in Parts 1, 3, 9 and 16 to 20.
The maximum Second Adult Rebate we can give is 25% off your Council Tax. When we work out
Council Tax Support we always check to see if you can get Second Adult Rebate. We will give you the
higher of either Council Tax Support or Second Adult Rebate.
About Council Tax Support for people of working age
The maximum Council Tax Support you can get is 80% of the Council Tax payable for a Band D
property. If you live in a property that is either Band E, F, G or H, we work out support based on the
Council Tax that would be payable if you lived in a Band D property. If you live in a Band A, B, C or D
property, the maximum Council Tax Support you can get will be 80% of your Council Tax liability.
If you have savings and investments of more than £6,000 you are not entitled to any Council Tax
Support.
Second Adult Rebate is not available to people of working age.
Changes you must tell us about
If you get Housing Benefit or Council Tax Support, we will carry out random checks to see if your
circumstances have changed. If something does change, you must tell us immediately. Do not wait
for us to check with you to report a change in your circumstances.
You must report changes in your circumstances by either writing to us or telephoning us on
0300 304 8000. You must tell us if
any of your children leave school or leave home
anyone (including you) moves into or out of your home, including lodgers and subtenants
your income or the income of anyone living with you, including benefits and tax credits, changes
your capital or savings change
you or anyone living with you starts work, becomes a student, goes on a Youth Training Scheme,
goes into hospital or a nursing home, goes into prison, or changes or leaves a job
your rent changes
you or your partner are going to be away from home for more than a month
anything you have told us in your claim form changes.
This is not a full list. If you are not sure, ask us for advice. If you do not tell the council about changes,
you may lose money you are entitled to or you may get too much benefit.
How we will collect and use information
Somerset West and Taunton Council is under a duty to protect the public funds it administers, and may
use the information you provide on this form for the prevention and detection of fraud. It may also share
this information with other bodies responsible for auditing or administering public funds for these
purposes. For more information, visit www.somersetwestandtaunton.gov.uk.
Housing Benefit and
Council Tax Support claim form
Part 1. You and your partner
By partner we mean someone you are married to, or live with
as if you are married.
If your relationship is with someone of the same gender, you must still
tick Yes to questions about your partner and provide information,
even if your relationship has not been recognised as a Civil Partnership.
Do you have a partner who normally lives with you?
Yes
No
If you have a partner, you must answer all the questions about them
You
Your partner
Surname or family name
First names
Any other family name or
surname you have used
Title (Mr, Mrs, Ms, other)
Date of birth
/ /
/ /
Your daytime telephone
number
Mobile phone number
Email address
(if you would like us to
contact you by Email)
National Insurance
number
You can find this on payslips or letters from Jobcentre Plus, the Pension Service or HM Revenue
and Customs. We cannot work out your claim if we do not have your National Insurance number.
Please tell us the full
address of the property
you want to claim for
including room number
Do not tell us your partner’s
address if it is the same as
yours.
Postcode
Postcode
What date did you move to
this address?
/ /
/ /
Do you want to claim
Tick all boxes that apply
Housing Benefit?
Council Tax Support?
Second Adult Rebate?
Is the property you
want to claim for
Tick all boxes that apply
Owned or mortgaged?
Rented from the Council?
Rented from a private
landlord?
Rented from a Housing
Association?
page 3
Part 1. You and your partner (continued)
You
Your partner
If you have moved home in
the last 12 months, tell us
your last address
Postcode
Postcode
Tell us if you were the
homeowner, a private tenant,
a council tenant or
a lodger at this address
Have you claimed Housing
Benefit or Council Tax
Support before?
Yes
No
Yes
No
When did you last claim?
/ /
/ /
Which Council did you claim
from?
What address did you claim
for?
Postcode
Postcode
If you are no longer at this
address, have you told the
Council you claimed from?
Yes
No
Yes
No
Have you come to live in
England, Northern Ireland,
Scotland, Wales, the
Republic of Ireland, the
Channel Islands or the Isle
of Man in last 5 years?
Yes
No
Yes
No
What is your nationality?
If your nationality is not
British, on what date did
you last enter and apply to
stay in the UK?
The UK is England, Northern
Ireland, Scotland and Wales.
/ /
/ /
Do you have the right to
reside in the UK?
Yes
No
Yes
No
Do you have recourse to
public funds?
Yes
No
Yes
No
What is your first
language?
page 4
Part 1. You and your partner (continued)
You
Your partner
Are you or your partner currently
working?
Yes
No
Yes
No
If No, tell us the date you last worked
/ /
/ /
Please tick if you or your partner is:
registered blind
on youth training
in legal custody
severely mentally impaired
an apprentice
getting a Personal Independence Payment
Are you or your partner a care
leaver?
Yes
No
Yes
No
By care leaver, we mean a person who spent at least 13 weeks in foster or residential care, or in
other arrangements outside their immediate or extended family, on or past their 16
th
birthday.
Do you or your partner get any
sickness or disability benefits?
Yes
No
Yes
No
Are you or your partner an
in-patient at a NHS hospital?
Yes
No
Yes
No
If Yes, tell us the date you went into
hospital
/ /
/ /
Does anyone get Carer’s
Allowance for looking after you or
your partner?
Yes
No
Yes
No
If Yes, who gets this payment?
Do you get Carer’s Allowance for
looking after anyone?
Yes
No
Yes
No
If Yes, tell us who you look after
Have you been told you are
entitled to Carer’s Allowance, even
if you do not receive it, because
you get another benefit instead?
Yes
No
Yes
No
Does anyone have Power of
Attorney for you or your partner?
Yes
No
Yes
No
If someone has Power of Attorney, please provide their details on a separate sheet of paper and
send it with the form. If you are sending a separate sheet of paper, tick this box.
We cannot work out your claim until we see proof of your identity, your address and your
National Insurance number. The checklist on page 21 tells you what we need.
page 5
Part 2. Children
We need to know about any children normally living with you who are:
under 16,
aged 16 or 17 and registered for work or youth training, or
aged 16 to 20 and in education doing a course not higher than
GCE A-level, SCE Higher level or GNVQ (advanced).
Are there any children in your household as
described above?
No
Go to Part 3
Yes
First child
Second child
Surname or family name
Other names
Relationship to you
Date of birth
/ /
/ /
Child Benefit number
Is the child registered blind or getting
Disability Living Allowance or a
Personal Independence Payment?
Yes
No
Yes
No
Third child
Fourth child
Surname or family name
Other names
Relationship to you
Date of birth
/ /
/ /
Child Benefit number
Is the child registered blind or getting
Disability Living Allowance or a
Personal Independence Payment?
Yes
No
Yes
No
If you have more than 4 children, use a separate sheet of paper to tell us all the information we
ask for and send it with the form. If you are sending a separate sheet of paper, tick this box.
Do you receive child maintenance or support payments
for any children living with you?
Yes
No
If Yes, how much do you get?
£
How often do you receive it?
Every
Do you pay for childcare?
For example, to a childminder, nursery or after school club.
Yes
No
Which children receive the
childcare?
How much do you pay after any Government or employer
contribution?
£
How often do you pay?
every
Does a Registered Childminder provide the care?
Yes
No
If Yes, tell us their registration number.
We must see proof of your children. The checklist on page 21 tells you what we need.
page 6
Part 3. Other people living in your home
Now tell us about all the people who usually live with you and your partner.
We need to know about people who are currently working away but who use your property as their
main home. Do not tell us about people who just share a hall, bathroom or toilet with you.
Do any adults usually live with you and your
partner?
By adults we mean people over 16 who nobody
gets Child Benefit for.
No
Go to Part 4
Yes
If you want to tell us about more than two people, use a separate sheet of paper to tell us all the
information we ask for in Part 3 and send it with the form.
If you are sending a separate sheet of paper, tick this box.
First person
Second person
Surname or family name
Other names
Date of birth
/ /
/ /
Their relationship to you
Some examples are aunt,
brother, daughter, father,
grandson, grandmother,
stepdaughter, joint tenant,
joint owner, subtenant,
lodger, boarder or friend.
National Insurance
number
Do they normally work for
16 hours or more a week?
Yes
No
Yes
No
If Yes, tell us their earnings
before any deductions
£
£
When did this person start
work?
/ /
/ /
Do they get Income Support,
income-based Jobseeker’s
Allowance, income-based
Employment and Support
Allowance or Pension Credit?
Yes
No
Yes
No
Are they a full-time student, a
student nurse, a care worker,
an apprentice or on youth
training?
Yes
No
Yes
No
Are they severely mentally
impaired?
Yes
No
Yes
No
Are they in hospital or legal
custody at the moment?
Yes
No
Yes
No
If Yes, when did they go in?
/ /
/ /
and when they are due to
come home (if you know)?
/ /
/ /
page 7
Part 3. Other people living in your home
(continued)
First person
Second person
Do they have any other
income?
Make sure you tell us about any
other income they have.
This includes interest from
savings and investments.
Yes
No
Yes
No
1. Where does this income
come from?
How much is it before
deductions?
£
£
2. Where does this income
come from?
How much is it before
deductions?
£
£
Are any of the people who normally live with you married to
each other or living together as partners
(see page 3 for what we mean by partner)
Yes
No
is the partner of (name)
If Yes, tell us their names
The checklist on page 22 tells you what we need for the people who live in your home.
Part 4. Income based Jobseeker’s Allowance, Pensioner Guarantee Credit,
income related Employment Support Allowance and Income Support
Are you or your partner getting or waiting
to hear about a claim for:
income based Jobseeker’s Allowance?
income related Employment Support Allowance?
Pensioner Guarantee Credit?
Income Support?
No
Go to Part 5
Yes
Are you or your partner actually getting:
income based Jobseeker’s Allowance,
income related Employment Support Allowance,
Pensioner Guarantee Credit or Income Support at
the moment?
Yes
No
If Yes, which benefit are
you getting?
When did you start getting it?
/ /
Go to Part 13
If No, are you or your partner waiting to hear about
a claim for income based Jobseeker’s Allowance,
income related Employment Support Allowance,
Pensioner Guarantee Credit or Income Support?
Yes
No
If Yes, which benefit are
you waiting for?
When did you claim?
/ /
We must see proof of your benefits or pensions before we can work out your claim.
The checklist on page 22 tells you what we need.
Part 5. Working for an employer
Do you or your partner work for an employer?
No
Go to Part 6
Yes
If you work for more than one employer, use a separate sheet of paper to tell us all the
information we ask for on this page and send it with the form.
If you are sending a separate sheet of paper, tick this box.
You
Your partner
When did you start this job?
/ /
/ /
What kind of work do you do?
What is the name and address
of your employer?
Postcode
Postcode
How many hours a week do
you work?
How often do you get paid?
every
every
How much do you normally
earn every week, or month?
£ every
£ every
When was your last pay rise?
/ /
/ /
When will your next pay rise be?
/ /
/ /
How are you paid?
For example, by cash, cheque
or straight into a bank account?
Do you pay into a pension scheme?
Yes
No
Yes
No
If Yes, how much do you pay?
£ every
£ every
Are you employed for a limited
time?
Yes
No
Yes
No
If Yes, when will you finish
work?
/ /
/ /
Do you receive a bonus, tips
or profit sharing?
Yes
No
Yes
No
If Yes, how much do you get?
£
£
How often do you receive it?
every
every
Are you currently getting
Statutory Sick Pay?
Statutory Paternity Pay?
Statutory Adoption Pay?
Statutory Maternity Pay?
Yes
No
Yes
No
Are you currently getting any
other sick pay or maternity pay
from your employer?
Yes
No
Yes
No
We must see proof of your earnings. The checklist on page 21 tells you what we need.
Part 6. Self-employment
employer
Are you or your partner self-employed?
No
Go to Part 7
Yes
You
Your partner
When did you start this job?
/ /
/ /
What kind of work do you do?
What is the business name
and address?
Postcode
Postcode
How many hours a week do
you work?
If you have audited accounts,
when will they be ready?
/ /
/ /
Do you pay into a pension
scheme?
Yes
No
Yes
No
If Yes, how much do you pay?
£ every
£ every
Do you get a Business
Start-Up Allowance?
Yes
No
Yes
No
If Yes, how much do you get?
£
£
We must see proof of your self-employment income. See the checklist on page 21
Part 7. Any other work or income from a business
Are you or your partner a director of any limited company or
receiving an income or dividend from any business?
This could be income you get from an investment or as a silent partner
Yes
No
If Yes, how much do you or your partner get?
£
How often do you receive it?
every
Do you or your partner do any other
work at all?
No
Go to Part 8
Yes
This could be voluntary work or any other work, even if it is not paid work
You
Your partner
When did you start this job?
/ /
/ /
What other work do you do?
What is the name and
address of the person you
work for?
Postcode
Postcode
How many hours a week do
you work?
Do you get paid?
Yes
No
Yes
No
If you only get expenses or tips, still tick Yes and give details
How much do you get before
any deductions?
£
£
How often do you get paid?
every
every
Part 8. Benefits, pensions & allowances
Are you or your partner getting any benefits,
pensions or allowances or are you waiting to
hear about a claim for any benefit, pension or
allowance?
No
Go to Part 9
Yes
Read the lists below and tell us about any benefits, pensions or allowances you or your partner
have claimed or get now. Tell us the full rate of benefits, pensions or allowances before deductions.
Benefits for illness or disability
Other Benefits
Attendance Allowance
Carer’s Allowance
Disability Living Allowance
Employment and Support Allowance
Incapacity Benefit
Industrial Death Benefit
Industrial Injuries Disablement Benefit
Mobility Supplement
Personal Independence Payment
Severe Disablement Allowance
Statutory Sick Pay
War Disablement Benefit
Bereavement Allowance
Child Benefit
Child Tax Credit
Fostering or adoption allowance
Government Training Allowance
Guardian’s Allowance
Jobseeker’s Allowance (contributions-based)
Maternity Allowance
Statutory Adoption pay
Statutory Maternity or Paternity Pay
Widow’s or Widower’s Benefit
Working Tax Credit
Universal Credit
Pensions
Pension Credit
State Retirement Pension
War Pension or War Widow’s Pension
If you are getting or have claimed any benefit not listed, make sure you tell us about it
You
Your partner
The name of the benefit,
pension or allowance.
Waiting to hear?
Yes
No
Yes
No
Getting now?
Yes
No
Yes
No
Amount received
£
£
How often?
every
every
The name of the benefit,
pension or allowance.
Waiting to hear?
Yes
No
Yes
No
Getting now?
Yes
No
Yes
No
Amount received
£
£
How often?
every
every
The name of the benefit,
pension or allowance.
Waiting to hear?
Yes
No
Yes
No
Getting now?
Yes
No
Yes
No
Amount received
£
£
How often?
every
every
We must see proof of your benefits, pensions or allowances.
The checklist on page 22 tells you what we need.
Part 9. Income from accommodation
Does anyone pay rent or money for board or
lodgings to you or your partner for living with
you?
No
Go to Part 10
Yes
First person
Second person
Name of the person making
the payment
Amount charged
£
£
How often
every
every
Does the payment include money for:
Food?
Yes
No
Yes
No
Heating?
Yes
No
Yes
No
Part 10. Other income
Do you, your partner, or any children you are
claiming for, have any money coming in
(or expect to have some money coming in)
that you have not already told us about on
this form?
We need to know about:
No
Go to Part 11
Yes
Private pensions
Occupational pensions
Work pensions
Any other pension
Training allowances
Charitable income
Student grants or loans
Early Years Grant
Money from a trust fund
Maintenance or support not
included in Part 2 of this form
Any money you expect to
get in the next 12 months
Any other income you have
not already told us about
You do not need to tell us about money from the Independent Living Fund, the Eileen Trust
or the MacFarlane Trust.
Other money 1
Other money 2
What is the money for?
Who gets it?
How much do they get?
£
£
How often
every
every
When did this income start?
/ /
/ /
When is it likely to go up
/ /
/ /
Other money 3
Other money 4
What is the money for?
Who gets it?
How much do they get?
£
£
How often
every
every
When did this income start?
/ /
/ /
When is it likely to go up
/ /
/ /
We must see proof of all income. The checklist on pages 21 and 22 tell you what we need.
page 12
Part 11. Bank accounts, savings and investments
You must tell us about ALL accounts you have, even if the account has a nil or overdrawn
balance. If you do not have an account, write “none”. If you’re overdrawn, write “overdrawn”.
If you have any money or investments abroad, you must tell us. Do not leave any space blank.
You
Your partner
Bank account(s)
£
£
£
£
Please tell us the account
numbers for any accounts
listed above
Building society account(s)
£
£
£
£
Please tell us the account
numbers for any accounts
listed above
Post Office accounts
£
£
Please tell us the account
numbers for any accounts
listed above
Accounts, savings,
investments or any money
held abroad
£
£
Premium bonds
£
£
PEPs, TESSAs and ISAs
£
£
National Savings Income
Bonds
£
£
Other savings:
for example, other savings
schemes, income bonds, trust
funds
£
£
£
£
Do you have any cash
savings?
Yes
No
Yes
No
If Yes, how much
£
£
Do you have any stocks,
shares or unit trusts?
Yes
No
Yes
No
Name
Number held
If Yes, give us details.
If there is not enough space,
enclose a separate sheet.
page 13
Part 11. Bank accounts, savings and investments (continued)
You
Your partner
Do you have any National
Savings Certificates?
Yes
No
Yes
No
If Yes, give details below. If there is not enough space, continue on a separate sheet.
Purchase date
Issue
Number of units held
/ /
£
/ /
£
Property
Do you own, or have any
financial interest, in any other
property either here or abroad?
Yes
No
Yes
No
If Yes, what is the address of
the property?
Postcode
Postcode
Are you trying to sell the property?
Yes
No
Yes
No
Tell us an approximate value of
the property
£
£
Is there a mortgage or money
owing on the property?
Yes
No
Yes
No
If Yes, how much is owed?
£
£
Is the property rented out?
Yes
No
Yes
No
Is the property lived in by a
relative who is over 60 or sick, or
by your previous partner?
Yes
No
Yes
No
If you have no cash or savings
write none in this box
We must see proof of your accounts, savings and any other investments you have.
Read the checklist on page 22 to see what we need.
Part 12. Students
Are you or your partner a student?
No
Go to Part 13
Yes
You
Your partner
Do you get a grant, loan or
bursary?
Yes
No
Yes
No
What qualification are you
studying for?
How long is the course for?
How many hours do you
study each week?
What is the first day of your
academic year?
/ /
/ /
What is the last day of your
academic year?
/ /
/ /
page 14
Part 13. Temporary absence
Are you or your partner temporarily away
from the address you are claiming for?
No
Go to Part 14
Yes
You
Your partner
What is your temporary
address?
Postcode
Postcode
What date did you move into
your temporary home?
/ /
/ /
Are you renting your home to
someone while you are away?
Yes
No
Yes
No
Do you intend to return to
your home?
Yes
No
Yes
No
When do you expect to
return home?
/ /
/ /
Part 14. Paying rent
Do you pay rent or site fees to a private
landlord or a Housing Association
No
Yes
What is your landlord’s full name and
business address
By landlord we mean the person or organisation
that owns the property you live in.
Postcode
If your landlord has an agent, tell us their
name and address. By agent we mean the
person or organisation you actually pay your
rent to.
Postcode
What is your landlord’s or agent’s telephone
number?
What is your landlord’s or agent’s e-mail
address?
Are you, your partner, or any of your own or
your partner’s children related to your
landlord or agent, or to your landlord’s
partner or the agent’s partner?
Related includes any connection through blood,
common law or marriage, even if the relationship
has ended. Some examples are ex-husband,
ex-wife, aunt, brother, daughter, father, grandson,
grandmother, son-in-law or stepdaughter.
No
Yes
What is the relationship?
is my landlord’s or agent’s
Have you, your partner, or any of your own or
your partner’s children ever had any financial
interest in the property?
No
Yes
Could you afford the rent when you moved in?
No
Yes
Part 14. Paying rent (continued)
How much rent do you pay and how often?
For example, every week, every fortnight,
every 4 weeks or monthly
£ every
How do you pay your rent?
For example, by cheque, cash, standing order,
direct debit etc.
Does anyone else share the rent with you
and your partner?
Yes
No
If Yes, tell us their names and their relationship to you
and your partner.
How much of the rent do they pay and how often?
£ every
Do you have any weeks when you do not
have to pay rent?
Yes
No
If Yes, how many weeks are there when you do not
have to pay rent?
Do you or your partner own any part of the
property?
Yes
No
Do you pay site rent?
Yes
No
If you started renting your home before
15 January 1989, has the Rent Officer
registered a fair rent for your home?
Yes
No
Does your home have central heating?
Yes
No
Does your home have a garden?
Yes
No
Does your home have a garage?
Yes
No
Do you use your home for business?
Yes
No
What sort of accommodation do you live in? Tick one box only
Detached house
Semi-detached house
Terraced house
Hotel
Detached bungalow
Semi-detached bungalow
Maisonette
Hostel
Board and lodgings
Flat over shop
Flat in a house
Flat in a block
Bedsit or rooms or
a studio flat
Caravan or mobile home
Residential nursing
home
Residential care
home
How many floors are there in the whole building?
Which floors do you live on? For example, all floors, ground floor, first floor
How many rooms are there?
In the whole
property
For you and your
family
Shared with other
people
Living rooms
Bedrooms
Kitchens
Bath or shower rooms
Toilets
Bedsitting rooms
Other rooms
Part 14. Paying rent (continued)
What sort of tenancy do you have?
For example, shorthold or assured, tied or
something like this.
How long is the tenancy for?
/ /
to
/ /
Is your home let as?
Fully furnished
Partly furnished
Hardly any furniture
Unfurnished
Does your rent include money for the following? (If you get a separate bill, it is not included.)
Included
Amount if known
Water and or sewerage rates
Yes
No
£
Heating for you and your family
Yes
No
£
Lighting for you and your family
Yes
No
£
Hot water for you and your family
Yes
No
£
Cooking fuel
Yes
No
£
Cleaning for you and your family
Yes
No
£
Laundry done by your landlord
Yes
No
£
Garden maintenance
Yes
No
£
Heating, lighting or cleaning of rooms you share
with others
Yes
No
£
Does your rent include any meals for you
and your family?
Yes
No
If Yes, what meals are provided?
Breakfast
All meals
Half-board
Do you live in supported accommodation?
Yes
No
If Yes, does your rent include…
Amount if known
General Counselling or support
Yes
No
£
An amount for an alarm system
Yes
No
£
Personal care
Yes
No
£
Caretaker, warden or estate staff
Yes
No
£
Cleaning your room or windows because you
are unable to do it yourself
Yes
No
£
Are you behind with your rent?
Yes
No
If Yes, by how many weeks?
Has your rent changed in the last 12 months?
If Yes, we need proof of the date it changed
Yes
No
When is the next rent increase due?
/ /
We must see proof of your rent and tenancy before we can work out your Housing Benefit.
Read the checklist on page 22 to see what we need.
page 17
Part 15. How we will pay you and the choices you have
If we award Council Tax Support, we will pay it into your Council Tax account.
If you are a Council Tenant, we will pay any Housing Benefit (Rent Rebate) into your rent account.
If you rent your home from a private landlord, we will usually pay your benefit to you and it is
then your responsibility to pay your rent to your landlord.
If you are in rent arrears we may make the first payment by cheque and we will send it to you but it
will be payable to your landlord.
After the first payment we will pay your Housing Benefit into your bank account every fortnight
Paying your benefit into a bank or building society account by Direct Credit is the easiest and safest
way to get your benefit. Please give us your account details below. We cannot pay into a Post
Office card account.
Name of bank or building society
Whose name is the account in?
Account number that you want us to pay the
money into. (Not a mortgage account)
Sort code
You can choose to have your Housing Benefit paid straight to your landlord if:
You live in supported accommodation
provided by a local authority, registered social
landlord, charity or voluntary organisation
You live in a caravan, houseboat, mobile
home or a hostel
You rent from a Housing Association
Your tenancy started before 15 January 1989
If there is a reason why we should pay your benefit to your landlord and not to you, please
tell us the reason in the box below.
Do you want us to pay any Housing Benefit
you are due to your landlord or their agent?
If you tick Yes, give the payment form on
page 23 to your landlord or agent.
Send it to us after they have completed it.
No
Go to Part 16
Yes
Go to Part 16
Part 16. Backdating
We usually award benefit from the Monday after the day we get your claim. Sometimes, we can pay
benefit from an earlier date if you have very good reasons for not claiming earlier.
Do you want us to backdate your claim?
No
Go to Part 17
Yes
Date you want to claim benefit from
/ /
For this earlier period, were your
circumstances the same as on this form?
No
Yes
Tell us why you did not claim earlier
Part 17. Any other information
Is there any other information you think we
should know?
No
Go to Part 18
Yes
Tell us any extra information below
Part 18. Giving information about you
Sharing information with your landlord
Sharing information with your landlord could help us to deal with your claim more quickly and
reduce the risk of you falling behind with your rent because of your claim being delayed.
If we pay your Housing Benefit directly to your landlord or to your Council rent account, then we can
discuss payment details (e.g. award dates and amounts) as we have to give your landlord this
information. We may need to confirm information with your landlord, for example the date you
started your tenancy. In these circumstances, we can contact your landlord without your permission.
If you give us permission to share information with your landlord, we would also be able to tell them:
If you have claimed Housing Benefit,
If we have made a decision on your claim,
If we have made a payment to you, or
If we need more information to make a decision and what it is we need.
You can withdraw your permission at any time.
We will not give your landlord any information about your personal or financial circumstances.
It will not affect your claim if you do not give us permission to discuss your claim with your landlord.
If you want to give us permission to share information with your landlord, please sign below.
I give the Council permission to share information
about the progress of my claim for Housing
Benefit with my landlord or their representative
Signature
Sharing information with other departments or authorities
Under the Data Protection Act 1998 we usually need your permission to discuss your claim with
other Council Departments or authorities responsible for public funds. This means we may not be
able to share information when we think you are entitled to extra help. For example, there may be
help available towards fuel costs for people who get Housing or Council Tax Support. You may
have to pay support charges in addition to your rent. If you get Housing Benefit, the County Council
may help you pay these charges, but we could not tell them you get Housing Benefit.
If you want us to share the information you give in this form with other Council Departments or
authorities responsible for public funds, please sign below.
I give the Council permission to share any
information about my claim for Housing Benefit or
Council Tax Support with other Departments or
authorities responsible for public funds.
Signature
You can withdraw your permission at any time.
It will not affect your claim if you do not give us permission.
Part 19. Declaration
Even if someone else has filled in this form for you, you must sign this declaration if you can.
If you have a partner, they must sign the declaration as well. Read this declaration carefully
before you sign and date it.
I declare that the information I have given on this form is correct and complete.
I know the information I give will be used to work out Council Tax Support I may be due through
Council Tax Reduction under S13a and Schedule 1a of the Local Government Finance Act 1992
I understand that if I give information that is incorrect or incomplete, you may take action
against me. This may include court action.
I agree that you will use the information I provide to work out Housing Benefit or Council Tax
Support, or both. You may check the information with other sources as allowed by law.
I understand you may use any information I provide in connection with this and any other claim
for social security benefits that I have made or may make. You may give some information to
other organisations, such as government departments, local authorities and private-sector
companies such as banks and organisations that may lend me money, if the law allows this.
I realise you may share information with Experian, a Credit Reference Agency
I understand fraud investigators could make checks for people I have not declared as living in
my home.
I agree to tell the Council immediately, in writing, about any change in my circumstances that
might affect my claim.
I have read the accompanying notes on pages 1 and 2 and I know the type of information
I must report and that I should not rely on anyone else to pass information to the Revenues
and Benefits Service
I know that if I do not report any changes that affect my award of Council Tax Support or
Housing Benefit, or I give incorrect or incomplete information, I must pay any Council Tax that
becomes due and pay any resulting Housing Benefit overpayment.
Signature of person claiming
Date
/ /
Partner’s signature
Date
/ /
If someone other than the person claiming has filled in this form, please tell us why you are
filling in the form for them.
I declare that as far as possible, I have confirmed with the person claiming that the answers written
on this form are correct.
Name of the person who filled in
the form
Signature of person who filled in
the form
Date
/ /
Relationship to the person
claiming
page 20
Part 20. Checklist
Please tick to say what evidence you are sending with this form.
We must see original documents, not copies.
Please do not send valuable items through the post. If you can, bring them to our offices. We will
take the details we need and give you the documents back straight away. If you cannot get into the
office, phone us for more advice.
If you do not provide all the evidence we need, we may not be able to pay you any benefit.
We need the same evidence for your partner, if you have one.
Evidence of identity
Such as a birth certificate, marriage certificate, passport, National Insurance number card,
medical card with NHS number, driving licence, UK residence permit, EEC identity card,
Home Office Standard Acknowledgment letter (SAL), recently paid utility bill, letter from the
DWP or the HM Revenue and Customs
We need at least 2 documents proving identity for each person.
Evidence you are living at the address you are claiming for
Such as a recently paid utility bill or a TV licence.
Evidence of National Insurance Number
Such as a National Insurance number card, P45, P60, payslips or letters from DWP or HM
Revenue and Customs.
Evidence of Children and childcare costs
Such as a letter from the DWP or HM Revenue and Customs showing the name of the child,
Child Benefit book or a Child Benefit award letter.
If you pay for childcare, we need to see a recent letter from the childcare provider giving
their name and address, names of the children receiving care, the amount charged and the
registration or a Childcare Payment Certificate completed by the childcare provider (see
page 25).
Evidence of Income Support, income-based Jobseeker’s Allowance,
income-based Employment and Support Allowance and Pensioner
Guarantee Credit
We need to see this for any other adults living in your home
Such as a benefit payment book showing the current address and the amount received.
Evidence of earnings (from employment or self-employment)
We need to see this for any other adults living in your home
Such as the last 5 weekly payslips or the last 2 monthly payslips, a Certificate of Earnings
completed and authenticated by the employer (see pages 26 and 27) or a letter from the
employer confirming the same details.
Self-employed persons must provide their most recent audited trading accounts or complete
the income and expenditure certificate on page 28.
page 21
Use your smartphone or mobile devise to take photographs of the evidence you need to support your claim.
Send your completed form and photos of your evidence to benefits@somersetwestandtaunton.gov.uk
If you send any evidence separately, make sure you put your full name and address in the email.
Part 20. Checklist (continued)
Evidence of benefits, pensions and allowances
We need to see this for any other adults living in your home
Such as current award notices, pension or order books or letters from the DWP or HM
Revenue and Customs showing how much is received.
Evidence of any other income
We need to see this for any other adults living in your home
Such as a recent letter, grant notification or advice slip from the person or organisation
paying the money or a letter from the Court showing maintenance payments. We also need
to see evidence of any money you receive from a tenant, boarder, lodger or sub-tenant.
The evidence you send must show the current amount paid, any deductions, and who
receives it
Evidence of money you pay out
Such as a recent letter from the pension company showing the amount and frequency of
payments and payslips showing the amount and frequency of pension contributions. If you
pay for the upkeep of a student, we need to see their student grant award notice, showing
the amount of contribution expected.
Evidence of capital, savings and investments
Such as bank statements, building society statements or passbooks, Post Office passbooks,
certificates for premium bonds, National Savings, ISAs, PEPs, TESSAs, stocks, shares,
income bonds and unit trusts.
The evidence you send must show transactions for at least the last two months
You only need to provide this evidence if your capital or savings are more than
£6,000
Evidence of private rent and tenancy
Such as a rent book, receipts, a letter from your landlord or a completed Rent Payment
Certificate (see page 24).
The evidence you send must be signed by your landlord or their agent and show your
name, address, amounts paid, dates of payment and any arrears
If this is your first claim at this address, we will need to see your tenancy agreement, a
Notice Of Registration (form R05) if your rent has been registered or a letter from the
landlord giving your name and address, the services included, rent payable, the date you
moved in and notice required.
page 22
Direct Payment Form Landlord’s Declaration
I am or I represent the landlord or landlady and I agree to the Council paying my tenant’s
Housing Benefit to me.
Tenant’s Name
Tenant’s Address
Postcode
I will tell the Council immediately in writing of any of the following changes known to me
Tenant moves out / moves to another flat or room
Changes to tenant’s household (people moving in or out)
Long absences by tenant
Tenant starts work
Any changes to the rent or services payable.
If your tenant is entitled to benefit we will pay their Housing Benefit to you by Direct Credit
Please give details of the bank or building society account you want any benefit to go into
Name of bank or building society
Whose name is the account in?
Account number that you want us to pay the
money into. (Not a mortgage account)
Sort code
Account roll number
(Building society accounts only)
I understand I may have to repay any overpaid Housing Benefit.
I agree to repay any lawfully recoverable overpayment if asked to do so by the Council.
Authorised signatory
Date
/ /
page
23
Proof of Rent Payment Certificate
Use this certificate only if you do not have any other proof of your rent payments. You landlord must
complete the section below and must give us his/her telephone number and address.
Tenant’s Name
Tenant’s Address
Postcode
Rent payable and frequency of
payment
£
every
What does the rent include?
What date has the rent been paid up to?
/ /
Amount of any arrears (if any)
£
Date the tenant moved into the property
/ /
What notice is required?
Landlord or Agent’s Name
Landlord or Agent’s Address
Postcode
Landlord or Agent’s signature
Date
/ /
Landlord or Agent’s telephone number
page 24
Proof of Childcare Payments
Name of person claiming benefit
Address of person claiming
Postcode
Name of childcare provider
Address of childcare provider
Postcode
Name of child or children being
cared for
Registration number of
childminder or playscheme
How much does your childminder or playscheme charge?
If you pay different amounts at different times, for example school holidays, please tell us how much
you pay and for how many weeks each year.
£
every week for
weeks
£
every week for
weeks
Which Council is your
childminder or playscheme
registered with?
Signature of person claiming
benefit
Date
/ /
Signature of childminder or
person representing playscheme
Date
/ /
page 25
Private and Confidential
Certificate of earnings
Employee’s Name
Employee’s payroll or
employment number
Employee’s Address
To the Employer
Please fill in this form showing your employee’s earnings. If you pay monthly, fill in the employee’s last two months’ wages.
If you pay weekly, fill in the employee’s last five weeks wages.
Period covered
Gross Pay
National
Insurance
Income Tax
Pension
Overtime
Net Pay
From
To
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
Tell us the gross income paid to this employee for the current financial year
£
How do you pay your employee? (cash, cheque, or directly into their bank account)
Amount
How often?
If your employee receives a bonus, profit sharing or tips please state the
amount and how often it is paid.
£
I certify this to be a correct statement of the earnings paid to this employee.
Employee’s National Insurance Number
Signature of Employer
Business Address
The employer must authenticate this form with the firm’s official stamp
If there is no official stamp, the employer must confirm details on company headed paper.
N.B. It is a criminal offence to give false information in support of a claim for benefit.
Please return the completed form to: -
Somerset West and Taunton Council, PO Box 866, Taunton TA1 9GS
Employer’s Official Stamp
p
age 26
Private and Confidential
Certificate of earnings
Employee’s Name
Employee’s payroll or
employment number
Employee’s Address
To the Employer
Please fill in this form showing your employee’s earnings. If you pay monthly, fill in the employee’s last two months’ wages.
If you pay weekly, fill in the employee’s last five weeks wages.
Period covered
Gross Pay
National
Insurance
Income Tax
Pension
Overtime
Net Pay
From
To
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
Tell us the gross income paid to this employee for the current financial year
£
How do you pay your employee? (cash, cheque, or directly into their bank account)
Amount
How often?
If your employee receives a bonus, profit sharing or tips please state the
amount and how often it is paid.
£
I certify this to be a correct statement of the earnings paid to this employee.
Employee’s National Insurance Number
Signature of Employer
Business Address
The employer must authenticate this form with the firm’s official stamp
If there is no official stamp, the employer must confirm details on company headed paper.
N.B. It is a criminal offence to give false information in support of a claim for benefit.
Please return the completed form to: -
Somerset West and Taunton Council, PO Box 866, Taunton TA1 9GS
Employer’s Official Stamp
p
age 2
7
Self-employed income and expenditure certificate
For the period from
/ /
to
/ /
=
weeks/days
Income
Total invoiced or billed including gratuities and tips
£
Expenditure
Accountancy or book-keeping charges
£
Advertising
£
Bank charges
£
Business entertainment
£
Business rates (NNDR)
£
Capital repayments on loans, mortgages or hire purchase agreements
£
Carriage or packing and delivery costs
£
Depreciation
£
Drawings (wages or salaries paid to owners of the business)
£
Heat, light, hot water for business use only
£
Hire or leasing charges
£
Insurance
£
Interest on loans, mortgages or hire purchase agreements
£
Money spent setting up or expanding the business
£
Petrol for business use only
£
Postage and stationery for business use only
£
Rent for business use only
£
Repairs not covered by insurance
£
Road tax for business use only
£
Stock or materials necessary to carry out your business
£
Telephone for business use only
£
Use of home as office
£
Wages or salaries paid to employees (excluding drawings)
£
Water rates for business use only
£
If you have any other expenses not listed above, please provide details
Total expenditure
£
Net profit
£
Declaration
I confirm the information I have given is true and complete. I will tell the Council immediately if the
income I receive from self-employment considerably increases or decreases.
Name of person running
business
Date
/ /
Signature of person running
business
Date
/ /
Name of person claiming benefit
Address of person claiming
benefit
Postcode
page 28
DO NOT COMPLETE THIS PART OF THE FORM IF YOU ARE THE OWNER OF A LIMITED COMPANY
Form revised April 2019
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