PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 1 Revised March 2013 Revenues & Benefits Service Hackney Service Centre, 1 Hillman Street, London E8 1DY Phone enquiries: 020 8356 3399 Fax: 020 8356 3655 Textphone: 020 8356 3725 Counter enquiries: Monday to Friday 9am to 5pm Email: benefits@hackney.gov.uk Website address: www.hackney.gov.uk Please write your Hackney Housing Benefit number in this box if you know it. Your first name: A claim form for Discretionary Housing Payment Part 1 Your details Your surname: Your address and postcode: Phone Number: Email Address: If you are receiving Housing Benefit but it does not cover all of your rent we may be able to help if you can t pay the difference. This is called a Discretionary Housing Payment and is meant to prevent hardship if you are in financial difficulties. The payments are temporary, and we can only pay them for a short time - how long will depend on your circumstances. The amount of money we can pay is limited, and each claim is considered on its own merits to make sure that payments are made to those most in need. You can also apply for Discretionary Housing Payments if you are receiving Housing Benefit but need to move to a new property and do not have the deposit, rent in advance, or removal costs. To claim this you must have found a property to move to, and reached an agreement with the landlord. Discretionary Housing Payments cannot be paid for the following: Service charges for services your landlord provides, such as water, heating and meals Increases in rent due to rent arrears Council Tax payments Shortfalls where Housing Benefit is not being paid Shortfalls in Housing Benefit caused by the recovery of an overpayment So that we can assess your circumstances please complete this form, and provide evidence to support your application.
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 2 What evidence you have to send in Check that you have completed all parts of the form Check that you have provided all the evidence asked for below. Remember that ONLY ORIGINAL DOCUMENTS WILL BE ACCEPTED A B C D E F G H I J Rent: Please provide a letter from your landlord confirming the level of rent arrears, your weekly rent and detailing any efforts you have made to negotiate a reduced rent. Alternative accommodation: If you have attempted to find alternative accommodation please provide evidence, eg a letter from a letting agency you have signed on with. Outgoings: Please provide your most recent utility bills. Debt repayments: Please provide letters from all your creditors confirming weekly repayments, the level of the debt and detailing any negotiations you have entered into to try to reduce your weekly expenditure. Income: Please provide payslips, student award letters, self-employed accounts, benefit payment books and original documentation confirming both your income and that of any other person living in your household. Savings: Please provide confirmation of any savings held by either yourself or any other person living in your household. Examples of the type of documentation you should provide includes current bank account statements, recently updated savings books and share certificates. Medical evidence: If you feel that there are medical factors which should lead to you being awarded additional payments of Housing Benefit please provide a letter from your doctor outlining the nature of these factors and any detrimental effect a failure to make a payment may have on your health. Rent in advance / deposit: Invoice or letter from prospective landlord confirming amount of deposit and rent due. Removal costs: Two estimates from removal companies giving the expected cost. Other documentation: Please provide any documentation you may have which supports any of the statements you have made in this application. 2
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 3 Part 2 Reasons for your claim (Continue on a page 11 if necessary - headed would you like to provide us with any additional information.) Part 3 Details about your address When did you move to this address Did you move in during the last 12 months? / / Go to Part 4. Answer the following questions. What was your previous address? Did you claim Housing Benefit at this address? If yes, why did you leave? Do you have any connection with this borough? If yes, please give details If no, why did you choose our area rather than another? 3
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 4 Part 4 Renting from a private landlord If your claim has been restricted by the rent officer, have you appealed against the decision Have you asked the landlord to reduce the rent? If yes, what was the outcome? Part 5 Your circumstances Have you received a notice seeking possession? Have you tried to find cheaper accommodation? Is there any reason why you could not move if you found cheaper accommodation? If yes, please give details. When does your tenancy end? / / How much notice would you have to give to end your tenancy early? Do you have any relatives or friends who could help you out? Could they provide you with accommodation, even if it is only temporarily? Could they, or anyone who lives with you, help you with your rent? Do you, or a member of your family, have any disabilities or health problems? If yes, please give full details. 4
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 5 Part 5 Your circumstances - continued Is your Housing Benefit less than your rent? If yes, by how much? How much rent do you pay? How much Housing Benefit do you receive? Could you pay your housing costs before you claimed Housing Benefit If yes, why can you no longer afford to do so? Has someone you lived with recently died? Your relationship to the person who died: Date of their death? / / Do you have any rent arrears? If yes, please tell us the amount and provide evidence (for example, a rent statement or a letter from your landlord). Do you have any other debts, such as hire purchase, loans, fines and so on? If yes, please give full details. Continue over page. 5
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 6 Part 5 Your circumstances - continued Do you or your partner have any savings, investments or property? (For Example, bank, building society or post office accounts, shares, unit trusts, ISA s, Premium Bonds, National Savings Certificates or Interests/Dividends received from investments or savings) If yes, please give full details below. Type of savings held Total amount Most recent value Do you have any savings or property (including holiday homes or timeshares) abroad? If yes, please give full details. If there is anything else you think we should know, give details What date do you want us to award a Discretionary Housing Payment from? (We can backdate awards, but because funds are limited, we would not usually consider backdating for more than four weeks.) If you want us to backdate your Discretionary Housing Payment, you should also explain why you did not claim earlier. 6
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 7 Part 6 Details of your income and spending In the table below, show the amounts of income and spending for you and your partner (the person you are married to or live with as if you were married). Income You Your partner How often? How much? How much? Wages or salary Child Benefit Child Tax Credit Working Tax Credit Income Support or Jobseeker s Allowance Pension Incapacity Benefit Other state benefits Contribution from lodgers and grown-up children Maintenance or Child Support Other (including any gifts or loans from family or friends) Grocery shopping (including food, toiletries and cleaning materials) Clothes Gas and electricity Water rates Rent or mortgage repayments (before benefits) Second mortgage or secured loan Payments to an endowment policy Insurance Ground rent or service charge Mobile phone Phone (landline) TV and video rental TV licence Satellite television Public transport Car costs School meals and meals at work Cigarettes Alcohol Maintenance Court fines Bank loans Social Fund loan Credit card payments Catalogue repayments Other please give details Spending You Your partner How often? How much? How much? 7
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 8 Part 7 To be completed only if you are applying for a rent deposit or rent in advance I wish to apply for Discretionary Housing Payment for: Rent deposit Rent in advance Removal costs How much are you applying for? Rent deposit Rent in advance Removal costs If this is for rent in advance, the period it covers is: From To How much is the monthly rent on the property you wish to move to? Address you are moving to Date you intend to move: Why do you need to move to a new address? Have you attempted to negotiate the amount of deposit or rent in advance with your prospective landlord? If so, what was the outcome? Would you be willing for our Housing Advice team to try and negotiate the amount of rent deposit or rent in advance with your landlord? If you have to pay the rent deposit or rent in advance yourself, what financial difficulties will this cause you? Do you have any other financial resources you could rely on i.e Family or Friends? If please give details. 8
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 9 Did you pay a deposit before you moved to your current address? How much was the deposit for? Will you get this deposit back? If not, please explain why not: Your new landlord s name and address: New property agent s name and address: Are you, your partner, or any of your children related to your new landlord / property agent? If yes please give details of the relationship: I would like the payment to go to: My bank account My landlord s bank account My property agent s bank account We will normally pay your landlord / property agent unless you provide proof that you have already paid the deposit yourself. If the payment is to be made to the landlord or agent, please provide their bank account details. Landlord s name and address: Name of Landlord s Bank: Address of Landlord s Bank: Name of Account Holder: Sort code: Account number: 9
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 10 Declaration I confirm that the information I have given is correct and complete. I understand that I could be prosecuted if I have given false information. I know that I must let you know about any change in my circumstances which might affect my claim. I agree that you can make enquiries to check the information I have given and that you may use this information to collect Council Tax and rent if necessary. Your signature Your partner s signature Date Date / / / / Extra declaration if someone else is filling in this form I have filled in this form for: I have read each question to this person and written down their answers. Signature Where did you hear about Discretionary Housing Payments? Date / / Guidance for filling in the form 1 You must answer all questions (except part 4 if you are not renting privately, and part 7 if you are not applying for a deposit/rent in advance). 2 You must provide relevant proof (for example, a statement of your rent arrears or evidence of loans). If you delay sending us this proof, it will take us longer to deal with your application as we will have to write to you for this information. (If you cannot get relevant proof at the time of your claim, please do not delay sending us your application as the date we award a payment from will depend on the date we receive your application. You should tell us that you will send us proof later, and send the proof to us as soon as possible.) 3 Please make sure that you provide full details of any exceptional circumstances, or reasons why you are having difficulties meeting your housing costs. If you need help or more information, please phone us on 020 8356 3399 or call into our office listed below. Hackney Revenues and Benefits Service Hackney Service Centre 1 Hillman Street, London E8 1DY. Phone: 020 8356 3399 Text Phone: 020 8356 3725 E-mail: benefits@hackney.gov.uk Open from Monday to Friday, 9am to 5pm. 10
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 11 Would you like to provide us with any additional information: 11
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 12 Ethnic monitoring (you do not have to fill in this section) To help us monitor the effectiveness of our equal-opportunities policy, please answer the following question. We will only use this information for monitoring purposes. Your Housing Benefit or Council Tax Benefit will not be affected if you do not fill in this section. What is your ethnic group? Choose one section from A to G, and then tick the appropriate box to show your ethnic background. A White British Irish Turkish Cypriot or Turkish-speaking (including Kurdish) Other Kurdish Other European Jewish Charedi (Orthodox Jewish) Irish traveller Gypsy or Roma Any other white background B Mixed White and black Caribbean White and black African White and Asian Any other mixed background C Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background D Black or black British Caribbean African Other black or black British (Please say which.) (Please say which.) (Please say which.) (Please say which.) (Please say which.) E Chinese Chinese F Vietnamese Vietnamese G Other Any other ethnic group (Please say which.) 12
PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 13 If you need help completing this form or would like to submit the form, please visit: Homerton Neighbourhood Office 92 Well Street, London E9 7JA rth West Neighbourhood Office Stoke Newington Municipal Building Stoke Newington, London N16 0JR rth East Neighbourhood Office (Council tenants only) 149 Stamford Hill, London N16 5LG Shoreditch Neighbourhood Office Bletchley Court, 1 Cropley Street, London N1 7PT DeBeauvoir & Queensbridge Neighbourhood Office 31 DeBeauvoir Road London N1 5SJ Clapton Park TMO The Housing Office 4A Gilpin Square London E5 0HL Suffolk Estate TMO (For Suffolk Estate Tenants only) The Housing Offices Welshpool Street London E8 4PF Hackney Revenues and Benefits Service Hackney Service Centre, 1 Hillman Street, London E8 1DY
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PS.8444c March 2013 Discretionary Form i_ps.8444c iv 09/04/2013 10:13 Page 16 Designed by DESIGNWORKS Hackney Council March 2013 PS.8444c