Non-residential carer –
Housing Benefit
additional room rate
application form
To apply for the additional room rate
please provide the following information.
Claimant name:
Benefit ref:
Claimant address:
Postcode:
Do you, your partner or a dependent child (up to age 20)
receive care from a non-residential carer? Yes No
Why do you (or the person receiving care) require an overnight carer?
When did this care begin? Please confirm the date:
Does the carer live at an address different to yours? Yes No
Does the carer provide care overnight? Yes No
Why do you (or the person receiving care) require an overnight carer?
How long do you expect this overnight care to last?
How regularly does the carer stay overnight to provide care? (tick as applicable)
State the number of nights weekly monthly other
Do you, or the person being cared for, receive any of the following:
• Attendance Allowance (AA) Yes No
• daily living component of Personal
Independence Payments (PIP) Yes No
• Armed Forces Independence Payment (AFIP) Yes No
• care component of Disability Living Allowance (DLA)
at the middle or high rate Yes No
Have you (or the person receiving non-residential
overnight care) claimed for PIP, AFIP, AA or DLA? Yes No
If you’ve answered yes to the previous question and the claim was rejected,
please explain why in the space below.
If PIP, AFIP, AA or DLA has not been claimed please explain why you have not made
a claim in the space below.
If you (or the person receiving overnight care) do not receive PIP, AFIP, AA or DLA
please provide evidence from a GP/social services/mental health worker etc. to
support the need for an overnight carer. Please enclose this with your application.
If you would like this information in another language
or format such as large print, CD or Braille, please visit
www.norwich.go.uk/intran or call 0344 980 3333
Please email completed form to: benefits@norwich.gov.uk
Alternatively you can send it to:
Benefts team
City Hall
Norwich, NR2 1NH
DPP11366 – 09/17
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