NORWICH
City Council
www.norwich.gov.uk
Housing benefit and council
tax reduction application
Use black ink to fill in the form.
Please complete every section of the form and answer all the questions. Any questions
that are not relevant to you should be marked ‘not applicable’ or crossed through.
Date issued:
Return by:
Part 1 – About you and your household
I am a: Council tenant Housing association tenant
Private tenant Owner occupier
Have you claimed before? Yes No If yes, where:
Have you claimed or are you in receipt of Universal Credit? Yes No
We will use this form to consider both Housing Benefit and Council Tax Reduction,
unless you state otherwise.
Claimant details
1
Title: Forename: Surname:
Date of birth: NI number:
Address:
Date you moved into this address:
Previous address:
Contact no.: Email address:
Nationality: Date first moved to UK
(if applicable):
Have you left the UK for longer than 6 months? Yes No
If yes, what date did you leave the UK?
Are you registered blind or disabled? Yes No Are you a full time student? Yes No
Are you a recent care leaver? Yes No
If yes, what date did you leave care?
Do you have a partner? Yes No
Partner details
Title: Name: Date of birth:
NI number:
Nationality: Date first moved to UK
(if applicable):
Are they a full time student? Yes No
Date they moved into this address:
www.norwich.gov.uk
2
Other adult, over 16 who nobody gets child benefit for (please complete additional information sheet if you
need to add more information)
Name NI number Date of
birth
Are they
a full time
student?
Relationship
to claimant
Does anyone get carer’s allowance for looking after you or your partner?
Yes No
Does anyone stay overnight to provide care for anyone in your household? Yes No
If yes, please state who:
The household has the following earnings (including self-employment):
(please refer to pages 8 and 9)
Household member Amount Frequency Hours per
week
Name of
employer
Children (please complete additional information sheet if you need to add more information)
Name Male or
female
Date of
birth
Is child
benefit
received?
Is child
tax credit
received?
Who
receives
the child
benefit?
Are they
registered
blind or
disabled?
Are there any children in your household? Yes No
Are there any other adults (over 16) in your household? Yes No
Please consider these for second adult rebate: Yes No
Does anybody in your household have any earnings? Yes No
Are they
working?
www.norwich.gov.uk
3
The household has the following money coming in (not earnings) or is waiting to
hear about it (eg state benefits/pension): (please refer to pages 8 and 9)
If you are in receipt of Child Tax Credits, you will need to provide your latest award letter.
Household member Type of income Amount Frequency
The household has the following bank accounts, ISAs, shares, savings, other
capital – including accounts held abroad:
(please refer to pages 8 and 9)
This should be completed for all accounts even if there is a zero balance.
Household member Type of
account/
capital
Account
number
Value/
balance
Do you have other property or land owned or in trust in this country or abroad with
or without mortgage outstanding?
Claimant: Yes* No
Partner: Yes* No
Other: Yes No
*If yes, please complete second property form
Myself or my partner pay the following expenses:
Child care costs: Yes* No
Name of childminder and registration no:
Amount:
Frequency:
*If yes please provide invoices showing these costs
Do you or your partner pay any private pension contributions? Yes No
Amount:
Frequency:
Does anybody in your household have any other
money coming in eg benefits or student finance? Yes No
Bank name
www.norwich.gov.uk
4
Rent details
Are you, or anyone in your household related to the landlord or owner? Yes No
If yes, what relation are they to you?
Is your landlord your former partner, or your partner’s former partner? Yes No
Have you previously owned this property? Yes No
Amount of rent: Frequency:
Date moved in: Joint tenancy: Yes No
Services included (eg water, heating, electricity):
Meals: Tenancy start date:
Part 2 – Property details
If you are a local authority tenant or you are only applying for council tax reduction you
do not need to complete the following section. Please go directly to Part 3 unless you would
like to give us information concerning a third party, please see Part 2 (sharing information).
Room type Total Own use Shared use
Living room
Bedsit room
Bedrooms
Bath/shower
Toilet
Kitchen
Other
Property type: (please tick)
House Bungalow Maisonette
Purpose built flat
Flat in house Studio flat
Flat over commercial property
Bedsit
Room House boat Hostel Caravan
Caravan site Other – give details
Do you and your household only occupy part of the property? Yes No
If yes, please state which floor you occupy:
If you only have one room, please indicate room number or where in the building it is
located, eg front, back, left, right:
Is the property furnished? Yes No
Do you have central heating?
Yes No
Do you have a garage? Yes No
Name and address of landlord/landlord’s agent – please include telephone
number and email if applicable:
www.norwich.gov.uk
5
In most cases, you will not be able to have payments made direct to your landlord.
However, if you feel you are unable to manage your rent payments, please attach
a separate page to explain why.
If you rent from a housing association – would you like your benefit Yes No
paid direct to them?
Do you occupy the property as a condition of you or your partner’s Yes No
employment?
I would like my benefit paid into this account (this cannot be a Post Office Card account).
We must see proof that the account is in your name. This must show your name, sort code and full account number
Name on the account:
Name of the bank/building society:
Sort code (all six numbers):
Account number (usually seven to ten digits):
Sharing information
I give Norwich City Council permission to share information about Yes No
my claim with my partner:
I give Norwich City Council permission to share information about Yes No
my claim with my landlord/landlord’s agent:
Name of landlord/landlord’s agent:
Telephone number: Email address:
I give Norwich City Council permission to share information about my claim with
a third party as specified below:
Name/details of third party:
Relationship to claimant:
Telephone number: Email address:
Part 3 – Other information
We can usually award benefit from the Monday after the day we receive your claim.
Sometimes we can award benefit/reduction from an earlier date if you have a good
reason for not claiming earlier. If you want us to consider awarding your benefit/reduction
from an earlier date, tell us when you want benefit/reduction from, and why you did
not apply for benefit/reduction earlier. Housing benefit can only be backdated for a
maximum of one month. Council tax reduction can be backdated for a maximum of
two months from the date we receive your request.
I would like you to consider backdating my housing benefit/council tax reduction
from:
Please tell us your reasons for any delay in making your application: (continue on a separate
sheet if necessary)
www.norwich.gov.uk
DPP10892 – 09/16
6
During this earlier period, what was your household income/capital?
(please provide proof of this)
Notes/additional information: (continue on a separate sheet if necessary)
Please read this declaration carefully before you sign and date it.
• I understand that this claim is made to you, my local council.
I declare that the information I have given on this form is correct and complete
as far as I know and believe.
I understand that if I knowingly give information that is incorrect or incomplete,
I may be liable to prosecution or other action being taken.
I agree that you will use the information I have provided to process my claim for
housing benefit or application for council tax reduction, or both. You may check
some of the information with other sources as allowed by the law.
I understand that you may use any information I have provided in connection with
this and any other claim for state 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.
I know that I must let you know in writing straight away about any changes in my
circumstances which might affect my claim. I understand that if I do not tell you about
any changes and you pay me too much benefit because of this, I may have to pay
back the extra benefit.
I understand that I may be prosecuted if I do not tell you about any change of circumstances.
If you do not supply all of the relevant proof within one month of Norwich City Council
receiving this form, your claim/application may not be considered.
Signature of claimant: Date:
Full name (print in capital letters):
Name of benefit officer:
7
Please use this space for any additional information.
www.norwich.gov.uk
www.norwich.gov.uk
8
Seven most wanted!
Norwich City Council
Revenues and benefits
1. Your fully completed and signed claim form – this means you must answer
every question.
2. Proof of identity for you and, if you have a partner, for him or her as well
(we will need two forms of identity for each of you).
3. Proof of National Insurance number for you (and your partner).
4. Proof of income for you (and your partner).
5. Proof of all income for anyone else living with you (including your children,
other relatives/friends).
6. Proof of any savings (if you or your partner jointly have more than £5,500 held in
a bank account, building society, or in other forms of investment such as stocks,
shares or properties).
7. Proof of rent (if you pay rent to a private landlord or housing association).
We will need to see both of the following:
a) Proof of current rent, and
b) One recent bank statement – in your name or your partner’s name so we can
pay benefit to you directly.
Every document you give us in support of your claim must be an original one, allthough
we can accept scanned copies via email of some of the evidence required (however
we cannot accept photocopies). Do not delay in sending us your claim form even if you
do not have all the relevant documents now.
Please provide your supporting evidence promptly.
You can contact us to check what can be accepted.
If you do not supply all of the relevant proof within one month of Norwich City Council
receiving this form, your claim/application may not be considered.
If you provide the following seven items we promise to process your
benefit claim in the shortest possible time.
Have you rounded up your seven most wanted?
Please see overleaf for information about evidence we can accept as proof.
www.norwich.gov.uk
9
DPP11348 08/17
Evidence we can accept
Proof of identity can be any of
the following:
Birth, marriage or divorce certificate,
separation or annulment papers
(in your current name).
• Passport (current and valid).
• TV licence in your name.
• Medical card.
Gas, electricity, phone or water rates bill,
in your name for the last quarter
(but not a mobile phone bill).
Full driving licence (photo card or paper).
Certificate of employment in HM Forces
or Merchant Navy.
Letter from solicitor, social worker
or probation officer.
UK Border Agency documents, relating
to entry into the UK.
Proof of your National Insurance number:
• P45 or P60.
Bank statements showing payments by
direct debit for Class 2 National Insurance
contributions or receipt of state benefits.
Pay slips or salary statement or works
pension statement. These must show
your National Insurance number.
Official letter sent to you by the
Department for Work and Pensions,
Jobcentre or HMRC tax department
(not hand written).
• National Insurance card.
Proof of income and capital:
Payslips (your last five weekly, your last three
fortnightly or your last two monthly payslips).
Trading accounts for the last financial year
if you are self-employed. If you have been
trading for less than a year we will contact
you regarding the information we need.
State benefit or HMRC tax credit award letters.
Bank, building society or post office
account pass books or statements
(we must see statements showing all
transactions for the last two months
for each account you have).
Share certificates or dividend statements
for stocks, shares and premium bonds.
Proof of rent:
Tenancy agreement – which is less than
52 weeks old.
If your tenancy agreement is more than
52 weeks old we will need confirmation
in writing from your landlord or property
agent confirming the amount of rent you
have to pay and any services included in
this amount.
• Rent book.
The evidence for proof of rent must
provide the following information:
The full name and business or home address
of the owner or agent of the property.
The date the tenancy agreement started.
• The amount of current rent payable.
What is included in the rent eg heating,
lighting, cleaning, water rates, meals,
personal care, general counselling
and support.
The payment period or frequency eg
weekly, monthly, four weekly.
Norwich City Council: City Hall, St. Peter’s Street, Norwich NR2 1NH
t: 0344 980 3333 e: benefits@norwich.gov.uk
This is not a full list of evidence which can be accepted. Please contact us for
other types of proof. Please provide proof of all your income and capital.
If you require this form in another language or format,
eg large print, CD or Braille, please call
0344 980 3333
or email info@norwich.gov.uk
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