NORWICH
City Council
www.norwich.gov.uk
To be completed by the tenant living in
accommodation where; care, support or supervision
is delivered to them by, or on behalf of, the landlord.
Please ensure this form is completed fully. All questions must be complete
before you return it to Norwich City Council. Failure to answer all questions
means that you will not receive Housing Benefit; you will need to make your
own arrangements to pay the rent and any service charges. You are
encouraged to provide detailed answers, to help us arrive at the correct
decision for you.
Tenant Accommodation
Questionnaire
Care support and supervision services
Revenues and benefits department
Tel: Customer contact team 0344 980 3333*
Text Relay users only (for people who are hearing impaired): 18001 01603 212587
www.Norwich.gov.uk/ContactUs
* Lines are open Monday to Friday, 9am to 4pm. Calls are charged as 01 or 02 numbers, depending on your phone
package. This means you can use mobile or landline ‘inclusive minutes’ to call us for free.
www.norwich.gov.uk
Full Name Address
Claim Number
National Insurance No.
1. Are there any specific reasons that you have been placed in this particular
accommodation?
(please detail)
2. Do you consider yourself to have any specific needs/difficulties that your landlord is
helping you with?
(please detail)
4. What are you expecting to gain from receiving the care, support or supervision service?
Eg working towards goals such as; resolving personal matters, learning skills or working towards other
outcomes, while you are living here, as a result of the service you receive? Please give us a brief
summary below.
6. If “No” please tell us briefly how your landlord ensures that you are regularly engaging with
the care, support or supervision service(s) that they provide.
3. Have you completed and signed an Individual Support Agreement with your landlord, or
the person/organisation providing the care, support or supervision service(s) to you?
Yes No
(If yes, please provide us with a copy)
3. Are you required to engage with the care, support or supervision service(s) as a condition
of your tenancy or license agreement?
Yes No
www.norwich.gov.uk
7. Do you regularly receive any care? Yes No
“Care” can mean you receive some help with your basic personal needs, for example; washing,
dressing, and preparing meals or medication and other similar basic daily tasks.
If yes, please tell us how often you receive the care service below.
My carer(s) visit me:
Daily Weekly Fortnightly Monthly Less often
Each visit, my carer(s) will usually stay for:
Please tell us how long in hours and minutes. If you are not sure exactly, or if the duration of the visit
varies each time, then please tell us the approximate length of an average visit
Is this service provided by your Landlord, as a part of your tenancy agreement? Yes No
If “No”, tell us who provides this service for you?
8. Do you regularly receive any support or supervision? Yes No
“Support, or supervision” can mean you receive some help with other things such as; finding long
term accommodation, returning to education or employment, managing financial problems or
learning to budget, support to help you addressing addictions, or handling other personal problems
and crisis situations.
If yes, please tell us how often you receive the support or supervision service below.
My support worker(s) visit me:
Daily Weekly Fortnightly Monthly Less often
Each visit, with my support worker(s) will usually last for:
Please tell us how long in hours and minutes. If you are not sure exactly, or if the duration of the visit
varies each time, then please tell us the approximate length of an average visit
Is this service provided by your Landlord, as a part of your tenancy agreement? Yes No
If “No”, tell us who provides this service for you?
If you receive care, support or supervision, your landlord or support worker will need to
countersign this form below, confirming that they have read and agree with both the content
and the information detailed on this form. You may supply additional information on a
separate sheet if you need to, but please ensure that each additional page you supply
is also countersigned.
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
www.norwich.gov.uk
COM11974 12/2018
Privacy notice
Norwich City Council is the data controller for
Housing Benefit and we have a legal obligation
to process your personal information. You may
contact our data protection and information
security officer by emailing dataprotection@
norwich.gov.uk or by calling 0344 980 3333.
What will we do with your data?
We use it to process your housing benefit claim/
application for Council Tax Reduction. We intend
to keep your data for six years plus the current
year, as stated in our Retention Schedule
available on our website.
What are your rights?
You have the right to request access to your
personal information to: ask for errors to be
corrected; restrict how your information is used;
object to how it is processed and request that
your data is deleted.
You also have the right to lodge a complaint
with the Information Commissioner’s Office if you
are not happy with how your data is processed.
What are the consequences of you not
providing data?
We would be unable to assess your claim for
Housing Benefit.
How will we share your data?
Information provided for Housing Benefit is shared
internally with IT services, revenues and housing
teams, and externally with the Department for
Work and Pensions (DWP) and Her Majesty’s
Revenue and Customs (HMRC) in order that
they may carry out their statutory duties.
Apart from where previously stated, we do not
pass your details to third parties unless we are
lawfully able to do so for the prevention and
detection of crime and fraud, or for the
collection of taxes.
Tenant declaration
I understand that it is my responsibility to advise Norwich City Council promptly whenever;
• My Individual Support Agreement changes or ends
• My Care, Support or Supervision Service changes or ends
• My rent liability or service charge changes or ends
• There are any other changes that may affect my Housing Benefit Claim/Council Tax Reduction
Tenant/Claimant signature Date
Landlord/Support Worker signature Name
Please return this form via email to www.norwich.gov.uk/contactus or post to:
Norwich City Council, City Hall, St Peter’s Street, Norwich, NR2 1NH
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