Fillable www.islington.gov.uk Housing and Council Tax Benefit Form_ZK_Layout 1 (London Borough of Islington)

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www.islington.gov.uk Housing and Council Tax Benefit Form_ZK_Layout 1 (London Borough of Islington)

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If you are on a low income, you could get Housing Benefit to help with your rent. You may also get
Council Tax Support to help pay your Council Tax. The benefits you can apply for are:
l
Housing Benefit for those that rent from a council or registered social landlord such as a housing
association
l
Local Housing Allowance for those that rent from a private landlord
l
‘Second Adult Discount’ is based on the income of other people living with you
l
Council Tax Support for those who have to pay Council Tax
If you have difficulty making a claim because you are elderly or disabled, we may be able to visit you
at home. Please contact us for help.
Return this form to us straight away or you may lose benefit. Do not delay returning the form
because you are waiting for evidence of earnings or rent. You can send evidence later, but make
sure we receive it within one month or we may not be able to pay you benefit. Make sure your
name and address are on anything you send us later.
You do not need to complete this form if you already have a current claim. If you are reporting a
change in your circumstances please complete a change of circumstances form instead.
Application form for Housing Benefit
(including Local Housing Allowance)
and/or Council Tax Support
(including Second Adult Discount)
www.islington.gov.uk
Please do not send valuable documents by post.
Area Housing Offices can photocopy documents for you.
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 1
Reset Form
Print Form
Look out for the new
TRANSLATIONS SYMBOL
If you see a council publication with the above symbol you
can have that publication explained to you in your own
language, either over the phone at any Islington housing
department office or, in some instances, a translation in
your language can be sent to you.
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 2
1
Declaration
Part 1
Even if someone else has filled in this form for you, you must sign this declaration. If you have a
partner, they must sign this declaration as well. Please read this declaration carefully before you sign
and date it.
I declare and agree with the following.
l
I declare the information I give on this form is correct and complete.
l
If I give information that is incorrect or incomplete, you may take action against me. This may also include
prosecuting me or charging fines.
l
If I am not fully entitled to any benefits declared and this results in you overpaying me benefit, you
may take action against me. This may also include prosecuting me or charging fines.
l
You will use the information I have provided to process my claim for Housing Benefit, Council Tax Support.
You may check the information I have provided with other sources within the council, other councils and
government agencies. This will include comparing the information I have given to other departments within
the council, other councils and government agencies.
l
I understand that this form will be held on computer and used to work out my Housing Benefit, Council Tax
Support.
l
You may use any information I have provided in connection with this and any other claim for social
security benefits, a discretionary housing payment or supported accommodation costs that I have
made or may make. You may give information to other government organisations if the law allows this.
l
I understand that you may contact the Home Office to check information I have given in this form
and to get any other relevant information.
l
I know I must let the benefits service know about any changes in my circumstances immediately which
might affect my claim, even if I have already told the DWP or any other organisation. I understand
that if I do not do this you may take action against me. This may include prosecuting me or charging fines.
l
I understand that you may contact me in writing, by phone, by email or by visiting me at home, for more
information so you can confirm I am still entitled to benefit.
l
I also understand that if you cannot contact me, you may have to suspend or end my claim.
l
Where Council Tax Liability ends and there is a credit, the Council may use this credit to reduce any
other sum that is owed to the Council.
1.1
Your signature Date
Your partner’s signature Date
/ /
/ /
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 1
2
Declaration - continued
Part 1
1.2
If someone else has completed
this form for you, please ask
them to state their full name,
their relationship to you and sign
below to confirm this
Your signature Date
/ /
1.3
I give the person named above permission to act as my representative and to be given information
about my claim
Your signature Date
/ /
1.4
I give consent for any information regarding my Housing Benefit/Council Tax
Support claim to be provided to the Council Tax department
No Yes
1.5
I give consent for any information regarding my Housing Benefit/Council Tax
Support claim to be provided to the Housing department (Council tenants only)
No Yes
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 2
3
Evidence you need to send in
You must provide all the evidence we need or we might not be able to award you benefit or support. We
need the same proof for your partner, if you have one, and for any other adults living in your home.
If you don’t have all the evidence we’ve asked for, send in your form immediately, delays may result in
you losing benefit or support. Please tell us what evidence is missing and why you cannot yet provide it.
You must send in any missing evidence within one month of returning your form, stating your name and
address on anything you send us later.
National Insurance number and identity - Original Documents only
We need evidence of your identity (ID) and National Insurance number. If you have a partner, we also need
proof of their National Insurance number and identity.
Please provide one of the documents from each box listed below for you and your partner if you have
one. Remember this must be an original document not a copy.
If you don’t have any of the above documents to prove your National Insurance number, please provide
one of the following documents as proof of your identity. Remember they must be originals and you should
do the same for your partner if you have one.
If any of the documents you supply for identity has your name and your partner’s name, we will
accept the document as identity for both of you.
Documents with a National Insurance number
l
Latest P45
l
Latest P60 - within the last two years
l
Official wage slips - within the last three
months, not handwritten
l
Letter from the tax office - dated within the
last 12 months
l
National Insurance number card
l
Current benefit notification letter from the
Department for Work and Pensions (DWP)
dated within the last 12 months
l
Bank or building society statement showing
welfare benefit paid into an account, but this
must quote your National Insurance number
Proof of identity
l
Current passport
l
Current EC residence permit
l
Current Aliens Registration Certificate
l
Current Immigration and Nationality Directorate
Travel Document
l
Full UK driving licence
l
Certificate of employment in HM Forces and
Merchant Navy
l
Immigration and Nationality Directorate
Standard Acknowledgement Letter (SAL)
l
Credit, debit, cheque cards
l
Birth or adoption certificate (original or official
copy of original)
l
Marriage certificate
l
Divorce, annulment or separation documents
l
Bank or building society statement or passbook
updated within the last year
l
Letter from a solicitor, social worker or a
probation officer
l
Life assurance or life insurance policy
l
Medical card
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 3
4
Rent
If you are a council tenant, you do not need to provide proof of rent. However, if you are a tenant of the
council’s co-operative scheme, provide your tenancy agreement. For all other tenants you must provide
one of the following.
l
An original tenancy or licence agreement. It must not be a copy
l
A letter from your landlord
l
A ‘proof of rent’ form for your landlord to fill in (we will provide one if you ask).
If you provide a letter, it must contain all of the following.
l
Your name and the address of where you are renting
l
The name and business address of the owner of the property
l
The name and business address of the managing agent (if relevant)
l
The date your tenancy began and the length of the tenancy
l
The amount of rent you pay
l
What services are included in the rent and a breakdown of those services
l
The property owner’s or managing agent’s signature
l
The names of joint tenants (if relevant)
l
How often you must pay your rent (weekly, monthly and so on).
State benefit income
(Not necessary if you receive Income Support and Job Seeker’s Allowance (income based)/Pension Credit
(guaranteed credit)/Employment and Support Allowance (income related).
For each benefit you receive we must see one of the following as proof.
l
Current letter from the DWP of your entitlement to benefit
l
Your latest bank or building society statements showing the payment being made into the account
l
A Tax Credit or Pension Credit letter.
Earnings from employment
We must see any of the following, which must be official payslips (not hand written).
l
Last five weekly payslips
l
Last two monthly payslips
l
Last three fortnightly payslips.
Self employed earnings
l
Audited accounts from an accountant
l
Your own profit-and-loss accounts.
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 4
5
Other income
Examples of other income are private pensions, student loans and maintenance from a former partner.
We will accept any one of the following as proof.
l
A current payment advice slip
l
A current bank or building society statement showing payments you have received
l
Current award notification letters
l
A current student loan award notification
l
A letter from absent parents confirming payments made
l
A letter from the organisation which gives you the money showing how much you get and how often
you get it.
Savings and investments
If you and your partner have savings (not necessary if you receive Income Support/Job Seeker’s Allowance
(income based)/Pension Credit (guaranteed credit)/Employment and Support Allowance (income related),
you will need to provide the following proof.
l
Bank or building society statements showing the last two months’ transactions
l
A savings book showing the current amount
l
Current proof of assets for certificates, shares, bonds, unit trusts, or a letter from ‘CREST’ (a certificate
holding company). However, if you have given us proof of these type of assets before and they have
not changed, you do not need to provide proof again
l
Provide evidence of all accounts with your name on including joint accounts.
Outgoings
l
Childcare charges - this must be a letter from the person you make payments to showing the amount
you pay, how often and the Ofsted registration number of the minder
l
Maintenance payments for your children who are students.
Non-dependants
We also need to see proof of the income and savings of people who live with you.
l
If they are on Income Support/Income-based Jobseeker’s Allowance/Pension credit-guarantee
credit/Employment and Support Allowance (income related), we only need proof of this
l
If they are not on Income Support/Income-based Jobseeker’s Allowance/Pension credit-guarantee
credit/Employment and Support Allowance (income related), we need proof of their income and savings.
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 5
6
Changes in circumstances
If your circumstances change, you must write to us at the Benefits Service immediately. If you do not,
and you receive benefit which you are not entitled to, you will have to pay it back.
If you deliberately do not tell us about a change in your circumstances because you would get less benefit,
we may take action against you. This could include prosecution.
If the change in your circumstances will result in you receiving more benefit/reduction, you must tell us
about it within one month or we will not be able to go back to the date of the change and you could lose
benefit.
The main circumstances that you must tell us about are shown below.
l
If you are not a council tenant and your rent changes
l
If anyone who lives in your household starts or stops getting Jobseeker’s Allowance, or any other
state benefit
l
If anyone who lives in your household starts or stops work
l
If any of your children leave school
l
If the wages of any child or non-dependant who lives with you goes up or down
l
If you have another child
l
If your or your partner’s income or savings go up or down
l
If you get married, separated or divorced
l
If there is any change in the number of people living with you
l
If the payments you receive from subtenants, boarders or lodgers change
l
If someone you look after stops getting Attendance Allowance
l
If you or your partner go into hospital for more than 52 weeks
l
If you or your partner go on holiday.
! These are only examples of changes that may affect your benefit. If you are in any doubt,
! please contact us.
Fair Processing Notice - How we use the information you give us
Any personal information you give us is held securely and will be used only for council purposes. Information
that was collected for one purpose may be used for another council purpose, unless there are legal
restrictions preventing this. Islington may share this information where necessary with other organisations,
including (but not limited to) where it is appropriate to protect public funds and/or prevent fraud in line
with the National Fraud Initiative guidelines.
Using your information in this way allows us to deliver more efficient services that can be tailored to your
individual needs and preferences. All personal information is held in strict confidence.
The use of data by the Audit Commission in a data matching exercise is carried out with statutory authority
under its powers in Part 2A of the Audit Commission Act 1998.
Housing Benefit and Council Tax fraud investigations may include checks on undeclared household members
such as cohabiters. Details regarding your Housing Benefit and Council Tax may be passed to a credit
reference agency such as Experian.
Please see www.islington.gov.uk/dataprotection for more information.
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 6
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Please complete all sections and cross through parts not applicable
Date issued (Day/Month/Year)
FOR OFFICE
USE ONLY
Date received stamp
Please tick appropriate box
Please provide us with your contact details (confirm the best time to contact you between 9-5pm)
Private tenant Owner occupier Joint owner occupier
Q2
Q3
Please state the number of bedrooms in the property
Previous claim number (if available)
! If you do not answer all the questions, it will delay your claim.
Q4
Q5
Telephone number
Email address
Q6
We may need to contact you in the future,
please tick your preferred method of contact
Phone
Post
Email
2.1
Address and postcode
2.2
Flat or room number (if any)
About you and your partner
Part 2
/ /
Q1
I wish to claim Housing Benefit Council Tax Support Both
Council tenant Shared ownership Housing Association tenant
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 7
8
2.3
Do you have a partner who normally lives with you?
2.4
2.5
2.6
2.7
2.8
Last Name
Other names
Title (Mr, Mrs, Ms or other)
National Insurance number
Date of birth (dd/mm/yyyy)
Have you or partner claimed
Housing Benefit or
Council Tax Support before? When did you claim? When did you claim?
What was the previous address at
which you claimed?
By partner we mean
l
a person you are married to or a person you live with as if you are married to them, or
l
a civil partner or a person you live with as if you are civil partners
If you have a partner, answer all the questions about them as well as yourself
YOUR PARTNER
/ /
YOU
/ /
/ // /
POSTCODE POSTCODE
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About you and your partner - continued
Part 2
No Yes
No YesNo Yes
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 8
9
2.9
If you have moved home in the last
12 months, tell us your last address
YOUR PARTNERYOU
2.10
2.11
2.12
2.13
2.14
Are you an asylum seeker?
Have you or your partner come to live in
England, Northern Ireland, Scotland,
Wales, the Republic of Ireland,
the Channel Islands or If ‘Yes’ we will write If ‘Yes’ we will write
the Isle of Man in the last two years? to you about this to you about this
What is your nationality?
If your nationality is not British on what
date did you come to live in the UK?
(The UK is England, Northern Ireland, Scotland and Wales)
Are you or your partner currently not
living at home for any reason, such as
in hospital, in prison or on holiday?
Date left
Date expected to return
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About you and your partner - continued
Part 2
No YesNo Yes
No YesNo Yes
No YesNo Yes
POSTCODE POSTCODE
/ // /
/ // /
/ // /
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 9
10
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About you and your partner - continued
Part 2
2.15
2.17
2.18
2.19
2.20
2.21
2.22
2.23
2.24
Are you living, or do you ever live, at an
address other than the one you have
already told us about? If ‘Yes’ what is the address? If ‘Yes’ what is the address?
Do you or your partner have
an invalid vehicle or car
under the Mobility Scheme?
Are you or your partner
receiving Attendance Allowance?
Are you or your partner
registered or certified blind?
Are you or your partner
receiving Disability Living Allowance
or Personal Independence Payment?
Are you or your partner a full time student?
(We may write to you separately about this)
Are you or your partner a student nurse?
Are you or your partner
an apprentice or on youth training?
Are you or your partner
long-term sick or disabled?
YOUR PARTNERYOU
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
POSTCODE POSTCODE
2.16
Were you in receipt of universal credit
at your previous address?
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 10
11
3.1
Do you have any children living with you who are under the age of 16 or under the age of 20 and still in
further education?
No
If ‘Yes’, please fill in the details below.
If you have more than three children, use a separate piece of paper.
Yes
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
Last name
Other names
Date of birth
Relationship to you
Male or female
Who gets Child
Benefit for them?
(Need to see proof of this)
Usual address of child if
different from yours
Does your child receive
Disability Living Allowance
or Personal Independence
Payment?
Are they registered or
certified blind?
! IMPORTANT
! You must let us know when your children leave school or if your Child Benefit stops
3rd CHILD2nd CHILD1st CHILD
/ // // /
If you are sending a separate sheet of paper, please tick this box
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Children and young people
Part 3
No YesNo YesNo Yes
No YesNo YesNo Yes
If ‘No’ go to Part 4
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 11
12
4.1
Do any other adults normally live with you and your partner? Do not
include your partner, people who pay you rent, joint tenants, joint
owners and children already listed in part 3. If you have more than
two adults living with you, use a separate piece of paper.
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
4.13
4.14
Last name
Other names
Date of birth
Relationship to you
Please state if any of these people are a couple
Do they receive Income Support,income-based
Jobseeker’s Allowance, pension (guarantee)
credit, or Employment and support allowance (income related)?
Do they receive any other benefit or Income?
If ‘Yes’, name the benefit/type of income
Amount
How often?
If they are working, how many hours a week?
Total amount of savings
Do they get Disability Living Allowance, Attendance
Allowance or Personal Independence Payment?
Are they registered or certified blind?
Are they a full-time student, a student nurse, a care
worker, an apprentice or on Youth Training?
Are they in hospital or in legal custody? If yes,
please tell us the date they are due back in Part 16
Do they have any other income?
(We will write to you about this)
2nd PERSON1st PERSON
/ // /
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If you are sending a separate sheet of paper, please tick this box
Other people who live with you
Part 4
No Yes
If ‘No’ go to Part 5
No YesNo Yes
£
EVERY
£
£
EVERY
£
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 12
13
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15
5.16
5.17
5.18
5.19
Are you or your partner getting Jobseeker’s
Allowance (income based), Income Support,
pension (guarantee) credit, or Employment
and support allowance (income related)?
Have you or your partner made a claim
and are now waiting for a decision?
Do you work?
How many hours do you work each week?
You must provide the full name and
address of your employer
When did you start this job?
How are you paid? (cash, cheque, BACs)
Do you get overtime, bonuses, tips or commission?
How much are you paid?
How often?
How much is your pay before deductions?
What is your payroll number?
Do you or your partner have a 2nd job? If yes
please give details on a separate piece of paper
Are you or your partner receiving Statutory
Sick Pay or Statutory Maternity Pay?
Are you self-employed?
Are you self-employed and receiving a
business start up loan?
Are you a company director?
If you are working, do you pay childcare
for any child aged under 15?
YOUR PARTNERYOU
5.1
Are you or your partner working or receiving any
benefits in 5.2 below?
Income
Part 5
No Yes
If ‘No’ go to Part 6
No YesNo Yes
No YesNo Yes
No YesNo Yes
If ‘Yes’ go to Part 11If ‘Yes’ go to Part 11
If ‘Yes’ go to Part 11If ‘Yes’ go to Part 11
££
££
/ // /
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 13
14
6.1
Do you or your partner have any of the following?
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
TYPE OF INCOME AMOUNT YOU GET HOW OFTEN AMOUNT YOU GET HOW OFTEN
Private pensions(s) or occupational pension(s)
State Pension
Widow’s or Widower’s Pension
War Disablement Pension
War Widow’s or Widower’s Pension
Guarantee credit (pension credit)
Savings credit (pension credit)
Are you paying money towards a
personal pension scheme?
If ‘Yes’, how much?
Have you paid into a private pension but
are not taking any or all of the private income?
If ‘Yes’, please provide the name
and address of the company
What is the policy number?
YOUR PARTNERYOU
TOTAL £
TOTAL £
£ £
£ £
£ £
£ £
£ £
£ £
£ £
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Pensions
Part 6
No Yes
If ‘No’ go to Part 7
No YesNo Yes
No YesNo Yes
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 14
15
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Family allowances
Part 7
7.1
Do you or your partner have any of the following?
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
7.13
7.14
7.15
7.16
7.17
TYPE OF INCOME AMOUNT YOU GET HOW OFTEN AMOUNT YOU GET HOW OFTEN
Child Benefit
Maternity Allowance
Foster Care Allowance
Guardian’s Allowance
Adoption or Custodian Allowance
Bereavement Allowance
Maintenance
Widowed Mother’s Allowance
Widowed Parent’s Allowance
Child Tax Credit
Working Tax Credit
Paternity Pay
Adoption Pay
Statutory Sick Pay
Maternity Pay
Jobseeker’s Allowance (contribution based)
YOUR PARTNERYOU
No Yes
If ‘No’ go to Part 8
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 15
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Disability allowances
Part 8
8.1
Do you or your partner have any of the following?
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
8.11
TYPE OF INCOME AMOUNT YOU GET HOW OFTEN AMOUNT YOU GET HOW OFTEN
Incapacity Benefit
Employment and support
allowance (contribution based)
Severe Disablement Benefit
Industrial Disablement Benefit
Industrial Death Benefit
Carer’s Allowance (if you receive the allowance
for looking after someone else)
Please tell us the name and address of the
person you are looking after
Carer’s Allowance (if someone else
receives the allowance for looking after you)
Do you have a carer who lives elsewhere
but who needs to stay overnight with you?
(we will contact you separately about this)
Have you or your partner ever
claimed Carer’s Allowance?
! Still tick ‘Yes’ if you were not paid any Carer’s Allowance. This could have been because you
! were better off getting another social security benefit.
YOUR PARTNERYOU
No Yes
If ‘No’ go to Part 9
No YesNo Yes
No YesNo Yes
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9.1
9.2
9.3
9.4
9.5
9.6
9.7
9.8
A youth training scheme
An annuity
Rental income from property in
this country or abroad
Any other income - what is it? (include cash
payments and compensation payments)
How much?
How often?
Do you or your partner pay any money
towards student loans for your children?
If ‘Yes’, how much?
A voluntary organisation or charity
Do you receive money from overseas?
How much?
How often?
State which country the money comes from
Please say what these payments are for
! You do not need to tell us about payments from Independent Living Fund, The Eileen Trust or the
! MacFarlane Trust
YOUR PARTNERYOU
££
££
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Other money
Part 9
Do you or your partner have any of the following?
If ‘Yes’, are you or your partner receiving money from any of the following?
No Yes
If ‘No’ go to Part 10
£ £
No YesNo Yes
No YesNo Yes
£ £
£ £
No YesNo Yes
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:14 Page 17
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Savings, investments and property
Part 10
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
10.9
10.10
10.11
10.12
10.13
YOUR PARTNERYOU
££
££
££
££
££
££
££
££
££
Do you or your partner have any of the following?
Bank account (one)
Bank account (two)
Bank account (three)
Bank account (four)
National Savings Certificates and Bonds
Premium Bonds
Post Office accounts
Number of unit trusts
Number of shares and name of company
ISAs
Do you or your partner have any joint accounts?
If ‘Yes’, please give the account name
The amount
Give details of any savings or
investments not listed above
Do you or your partner own or partly own any
property, other than the home you live in,
either in the UK or abroad?
If you ticked ‘Yes’ we will need more information
(We will write to you about this)
If ‘Yes’, give the amount. You must include all accounts with your names
including joint accounts and please include account numbers.
No Yes
If ‘No’ go to Part 11
No YesNo Yes
No YesNo Yes
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19
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LAST NAME OTHER NAMES RELATIONSHIP TO YOU
Tenancy details
Part 11
11.1
Do you pay rent for your home?
11.2
11.3
11.4
11.5
11.6
11.7
YOUR PARTNERYOU
/ /
/ /
Date your tenancy started (day/month/year)
Date your moved in (day/month/year)
Do you have a tenancy agreement?
How long is it for?
What type of tenancy do you have?
Other than you and your partner, are any of the people who live in the
property joint owners or joint tenants?
If ‘Yes’, please give their names below.
No YesNo Yes
No Yes
No Yes
If ‘No’ go to Part 17If ‘No’ go to Part 17
11.8
11.9
11.10
11.11
11.12
11.13
Have you been placed here by a council’s
homeless person’s unit or social services?
Do you pay rent to the council?
If ‘Yes’, say which council
Are you a tenant of a council cooperative scheme?
If you are under 22 were you in Local Authority
Care before you moved to this address?
If you are aged 25-34 have you lived for 13 weeks
or more in a hostel for homeless people?
Has someone in your household died within the last 12 months?
Name of person
Relationship to you or your partner
Date they died
YOUR PARTNERYOU
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No YesNo Yes
No Yes
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:15 Page 19
20
12.1
12.2
12.3
How much rent do you pay?
How often do you pay rent?
If none of these, please
say how often
Are any of the following included in your rent? (If ‘Yes’, fill in the following.)
YES AMOUNT
Heating
Lighting
Hot water
Fuel for cooking
Water rates
Council Tax
Garage or parking
TV
Satellite television
Cable television
Cleaning service
Do you pay any service charges separate
from your rent for facilities such as cleaning,
lighting and so on in shared areas?
Does anyone else share the rent with you and your partner?
Has your rent changed in the last 12 months?
When is the next rent increase due? (day/month/year)
Has your rent been registered as a fair rent?
If ‘Yes’, when? (day/month/year)
If ‘Yes’, what are their names?
Weekly
£
2 Wks 4 Wks Monthly
About your rent
Part 12
If you are a council tenant go to Part 17
No Yes
No Yes
No Yes
No Yes
12.4
12.5
12.6
12.7
12.8
12.9
12.10
12.11
12.12
12.13
12.14
12.25
12.26
12.27
12.28
12.29
£
YES AMOUNT
Laundry
Counselling or support
Nursing
Personal care
Breakfast
Lunch
Evening meal
Gardening
Decoration
Other
Please give details
If ‘Yes’ how much?
12.15
12.16
12.17
12.18
12.19
12.20
12.21
12.22
12.23
12.24
£
£
£
£
£
£
£
£
£
£
£
/ /
/ /
£
£
£
£
£
£
£
£
£
£
No
Yes
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:15 Page 20
21
13.1
13.2
13.3
13.4
13.5
13.6
13.7
13.8
13.9
13.18
13.19
13.20
13.21
13.22
13.23
13.24
13.25
13.26
Detached house
Semi-detached house
Terraced house
Self-contained bedsit
Room in a house
Flat in a block of flats
Flat over a shop
Maisonette
Flat in a house
If none of the above, please give details:
How many floors are there in the building you live in?
Which floor or floors do you live on?
Is the property you rent:
If you live in a room or bedsit, are there any cooking facilities?
Has your home been adapted for someone with a disability?
Do you have central heating?
Who is responsible for decorating the inside
of your home?
Do you have a garage?
If you ticked ‘Other’, please say where.
Please tick the type of accommodation you live in.
13.10
13.11
13.12
13.13
13.14
13.15
13.16
13.17
Bedsit with shared facilities
Guest house or hotel
Residential nursing home
Residential care home
Studio flat
Caravan
Houseboat
Hostel or refuge
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About where you live
Part 13
Basement Ground First
partly furnished
fully furnished barely furnished unfurnished
Second Third Other
No Yes
No Yes
No Yes
Don’t knowLandlordYou
No Yes
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13.26
13.27
13.28
13.29
13.30
13.31
13.32
13.33
! IMPORTANT. If you use a room, rooms or flat in part of a house you must tell us where it is in
! the property.
Is it in:
In the table below, please tell us how many rooms you have.
Living or dining rooms
Bedrooms
Bedsitting rooms
Kitchens
Bathrooms
Toilets
Other - please say
13.34
13.35
13.36
Facing your property from the road,
is your own room on the left,
in the middle or on the right
of the building?
Please mark your room with an X.
Is your own room at the front, centre
or at the back of the building?
Please mark your room with an X.
If your room is somewhere different,
please say where
! You only need to fill in this part if you are renting a room in a property
HOW MANY ROOMS
DO YOU SHARE?
HOW MANY ROOMS ARE
FOR YOUR USE ONLY?
TOTAL NUMBER OF ROOMS
IN YOUR HOUSE OR FLAT
ccc
LMR
F
C
B
c
c
c
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About where you live - continued
Part 13
the centre?the back?the front?
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23
14.1
14.2
14.3
14.4
14.5
14.6
Please give the name and business address of your landlord, landlady or agent
Last name
Address
Telephone
If it is an agent please tick this box
If your landlord or landlady is a company, do you or your
partner have any connection with the company?
Is your landlord, landlady or agent related to you,
your partner or children?
If ‘Yes’, who is related to who and how?
Does the landlord, landlady or agent live in the property?
Do you owe your landlord or landlady any rent?
If ‘Yes’, how much?
Have you ever owned the property you are now living in?
If ‘Yes’, please give the date you sold it and the reason
£
/ /
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Other names
About your landlord or landlady
Part 14
No Yes
No Yes
No Yes
No Yes
No Yes
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24
15.1
15.2
15.3
15.4
15.5
We will pay your housing benefit straight into your bank or building society account. Generally we will only pay
your landlord if you are a housing association tenant.
Are you likely to have difficulty managing your finances?
Is it likely that you will use your benefit to pay your rent?
Has your landlord reduced the rent (or not increased the rent) to
make it affordable to you? (we will contact you separately about this)
I want my benefit to go straight to my landlord and I am a housing
association tenant? If you tick this box both you and your landlord
have to fill in the additional declaration in part 19.
Tell us the following details:
Name of bank or building society
Address and postcode
Give account name as it appears
on your bank statement
Account number
Sort code
! Please note that we will not be paying claims by cheque. If your bank details are not provided we
! cannot start paying benefit.
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How you want to be paid
Part 15
No Yes
No Yes
No Yes
Go to Part 16
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:15 Page 24
25
16.1
16.2
16.3
16.4
Are you a boarder or do you live in a hostel or refuge?
If ‘Yes’, how many meals does your landlord or landlady provide?
If your rent includes any of the following services, please tick the box and write the amount if you know it.
Do you share your room with anyone who is not your partner
or who is not related to you?
Please use for anything else you wish to tell us about, including any benefits or pension claimed but not
yet received, or other income/capital expected in the future.
Laundry (sheets)
Personal laundry
£
Cleaning
£
£
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Boarders and people who live in a hostel
Part 16
None
Breakfast Less than 3 meals All meals
No Yes
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26
We can usually award benefit from the Monday after the day we receive your claim. Sometimes we can pay benefit
from an earlier date if you have a good reason for not claiming earlier. If you want us to consider paying your benefit
from an earlier date, tell us when you want benefit from and why you did not claim earlier.
17.1
17.2
Date you want your benefit to be paid from (day/month/year)
Tell us why you did not claim earlier.
Please give as much detail as possible and provide any evidence you have, because we cannot normally
back date claims.
/ /
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Backdating
Part 17
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:15 Page 26
27
18.1
We are committed to an equal opportunities policy. To help us carry out this policy and to make sure that
we do not treat anyone unfavourably for any reason, please provide the following information. This is to
allow us to monitor our policy. We will not use the information for any other purpose.
I would describe myself as: (tick one box only)
White
Mixed
Black or Black British
Asian or Asian British Chinese
A British
Declaration
Part 18
D White/Black Caribbean
E White/Black African
F White and Asian
G Other
The Disability Discrimination Act 1995 states that a person has a disability ‘if he has a physical or mental
impairment which has a substantial and long-term adverse effect on his ability to carry out normal
day-to-day activities’.
Do you consider yourself disabled using this definition?
How would you define your gender?
And your sexuality?
And your religion/belief?
H Indian O Chinese
B Irish I Pakistani P Other
Q Greek/Greek Cypriot
R Turkish/Turkish Cypriot
C Other J Bangladeshi
K Other
L Caribbean
M African
N Other
Female
Male Transgender (M-F) Transgender (F-M)
Heterosexual Transexual Gay Lesbian Bisexual
Buddhist
Christian Hindu Jewish
Muslim
No religion Rastafarian Sikh
Any other
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:15 Page 27
28
If you want us to pay your benefit straight to your landlord, you must sign this declaration.
Please pay my Housing Benefit straight to my landlord. I understand that:
l I must always tell you about any change in my circumstances
l If I do not tell you about any change of circumstances and you pay me too much benefit because
of this, I will have to pay back the extra benefit; and
l I may be prosecuted if I do not tell you about any change of circumstances.
19.1
Now ask your landlord to sign this agreement
Landlords name
I agree to accept Housing Benefit payments for the tenant named in this form.
I understand that by law:
l I must tell you straight away if I find out about any change in the tenant’s circumstances
l You can stop paying benefit to me if I do not tell you about any change of circumstances
l I can be prosecuted if I accept Housing Benefit which I know I am not entitled to and;
l If you pay me too much Housing Benefit for any tenant, I must repay it. You can take the amount
of overpaid benefit from the benefit I get for any other tenants. This will not affect their rent.
19.2
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Paying benefit to your landlord
Part 19
Signature Date
/ /
Signature Date
/ /
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:15 Page 28
29
Sharing information with your landlord
Sometimes, sharing information with your landlord helps us to deal with your claim quickly and reduces
the risk of you falling behind with your rent because of your claim being delayed. We would only share
information with your landlord if you:
l are a local authority tenant; or
l have agreed that your Housing Benefit can be paid directly to your landlord.
But in either case, under the Data Protection Act we need your permission to share information.
If you give us permission, we would be able to tell your landlord:
l whether or not you had claimed or renewed your claim for Housing Benefit and, if so, whether
we have made a decision on your claim or not; and
l if we need further information to make a decision on your claim, and if so what information this is.
We will not give your landlord any information about:
l your personal or household circumstances; or
l your financial circumstances
If you do not give us permission to discuss your claim with your landlord, it will not affect your claim. And
if you give us permission but then change your mind, we will follow your wishes. Just contact us and let
us know.
I give Islington permission to share my information about the progress of my Housing
Benefit claim with my landlord or other representative.
Signature
Address and date
Date
19.2
/ /
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Paying benefit to your landlord - continued
Part 19
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:15 Page 29
When benefit will start from
If you are applying for benefit/reduction for the first time or your benefit/reduction has stopped, fill in and
return this form immediately as we will normally only pay benefit/reduction from the Monday after we receive it.
If you answer all the questions on the form and send us all the proof we need, we will contact you within 14 days, or
as soon as possible after that, to tell you if you are entitled to benefit/reduction. If you do not have all the information
we need, send the application form in now and the proof within one month, or you may lose benefit/reduction.
Where to take your form
Holland Walk Area Housing Office
85-88 Holland Walk
London N19 3XS
Phone: 020 7527 7480
Customer Centre
222 Upper Street, London N1 1XR
Email: contact@islington.gov.uk
Phone: 020 7527 2000
Fax: 020 7527 5001
Minicom: 020 7527 1900
Web: www.islington.gov.uk
Where to send your form
Benefits Service
PO Box 34750 Phone: 020 7527 4990
London N7 9WF Minicom: 020 7527 3628
Email: benefits.service@islington.gov.uk SMS: 07957 151231
Manage your housing benefit and council tax much quicker online!
Register for My eAccount and you can access all council services you need online 24 hours a day,
7 days a week. From checking your Housing Benefit and Council Tax Support entitlement, paying
your rent, or council tax, down to reporting dog fouling or littering on your street, plus lots more!
Log on at www.islington.gov.uk/myaccount
Not registered yet? It’s simple - you can do so in six steps:
l
Visit www.islington.gov.uk/myaccount or scan the QR code to be taken straight there
l
Once registered, log in and choose the service you need from the list of council services
For more details on benefits visit www.islington.gov.uk/benefits
Useful numbers
Sheltered housing 020 7527 5395
Repairs (8am to 8pm) 0800 694 3344
Emergency out of hours repairs 020 7527 5400
Federation of Islington Tenants Association 020 7226 9246
Benefits service 020 7527 4990
Freephone housing benefit fraud hotline 0800 073 1449
Empty property hotline 020 7527 6080
Home ownership 020 7527 7754
Linkline community alarm service 020 7527 5456
If you would like this document in large print or Braille, audiotape or in
another language, please contact 020 7527 2000.
Housing and Council Tax Benefit Form_ZK_Layout 1 22/12/2014 13:15 Page 30
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