Application form for Housing Benefit, Council Tax Benefit and Second Adult Rebate

HC BEN 1 Application form for Housing Benefit, Council Tax Benefit and Second Adult Rebate If you and/or your partner have capital of more than 16,000 and you or your partner are in receipt of Job Seeker s Allowance Income Based, Employment Support Allowance Income Based, Income Support or Pension Credit Guarantee you will qualify for Housing Benefit and/or Council Tax Benefit. You may claim Second Adult Rebate regardless of income or capital (see Guidance Notes 2 for details). If you and/or your partner have capital of more than 16,000 and you are not in receipt of the benefits listed in this paragraph, you will not qualify for Housing Benefit/Council Tax Benefit and should not therefore submit an application form to us. To avoid losing benefit you should fully complete, sign and return this form complete with all of the required information and proof requested as quickly as possible. Applicant s name and address Name... Address......... Postcode... Read the guidance notes contained within this form and then complete and return this form together with all information and proof requested as quickly as possible to a designated office at: The Operations Team, The Highland Council, PO BOX 5650, Inverness IV3 5YX PLEASE COMPLETE THIS SECTION The form should be completed in black ink and block capitals. FOR OFFICIAL USE ONLY About your home (tick every box which applies) Do you: Rent from the council? Rent from a private landlord? Rent from a housing association? Live in a hostel? Live in homeless accommodation? Have a joint tenancy? Have a life rent agreement? Own your home? Jointly own your home? Other? (please give details below)...... Claim number CT ref. number Rent ref. number Date issued Date of first contact Reason for issue NEW/CIC/INT Date Received: Do you sub-let your house? Yes No Do you use your home for Yes No business purposes? We may contact you for further information. PR08-132-F FEB10 v6

Please tear out and read the Guidance Notes on the opposite page before you complete this form. About you and your partner A You must answer each question by completing every section fully and ticking either Yes or No box. We will return your form if you fail to answer any question or sign this form. If you are single or separated, complete only sections headed You. If you have a partner, complete sections for both you and your partner. See Guidance Note 3. Second Adult Rebate - if you are claiming only Second Adult Rebate tick this box and please complete Sections A, C, and J only. To find out more about Second Adult Rebate, see Guidance Note 2. Title (Mr/Mrs/Miss/Ms) YOU PARTNER Surname Other names Date of birth D D / M M / Y Y Y Y D D / M M / Y Y Y Y Tick one of the following boxes. Are you: Single Daytime telephone number: Email address: Married, living together or Civil Partner Separated Divorced Widowed National Insurance Number: LETTERS NUMBERS LETTER LETTERS NUMBERS LETTER If you do not have a National Insurance Number please tick this box. Give details of any other names you have used. What nationality are you? Have you lived in the UK for the whole of the last 2 years? If you answer No you will have to provide more information. We will contact you about this. What date did you move into this address? D D / M M / Y Y Y Y D D / M M / Y Y Y Y If you have not yet moved into this address give the date you intend to move in. D D / M M / Y Y Y Y D D / M M / Y Y Y Y Is this your main home? If No, state the address of your main home. 2 Continued overleaf...

GUIDANCE NOTES - Housing Benefit, Council Tax Benefit and Second Adult Rebate We hold a register of people who are visually impaired. To have your name added to this register or to request this form in an alternative format eg. Large Print, braille, computer disc, audio tape, or suitable language, please contact any Council Service Point. Please tear out and read these notes carefully before you fill in the form. You should keep the notes in a safe place in case you need to refer to them later. Please complete the form in black ink and block capitals and return complete with all of the required information as quickly as possible to a designated office at: The Operations Team, The Highland Council, PO BOX 5650, Inverness IV3 5YX. Our other designated offices are listed on our website at www.highland.gov.uk or can be obtained by calling us on 0800 393 811. 1. What is Housing Benefit and Council Tax Benefit? Housing Benefit and Council Tax Benefit are state benefits to help you pay your rent and council tax if you are on a low income. Depending on your income and circumstances, we can pay up to 100% of your rent and council tax. You will have to pay for your water and waste water charges, as the benefit scheme does not cover these charges. Housing Benefit cannot help with costs such as mortgage payments, most fuel costs, cost of meals, water charges, personal laundry, care charges or cleaning. You cannot claim Housing Benefit if you live in the same property as your landlord and they are a close relative such as a parent, step-parent, son, daughter, stepson, stepdaughter or their partners. There are other circumstances where you may not qualify for benefit because of your relationship to your landlord. When you claim benefit, we will contact you if any of these apply. Local Housing Allowance Local Housing Allowance was introduced on 7 April 2008. It is a way of working out Housing Benefit for tenants renting accommodation on or after 7 April 2008 from a private landlord or existing Housing Benefit claimants who move address. Local Housing Allowance is not based on the property in which you live. It is based on: Who lives with you; Which area you live in; How much money you have coming in; and What savings or capital you have. If you live in Council accommodation or other social housing, Local Housing Allowance will not affect you. 2. What is Second Adult Rebate? If your income or capital is too high for you to qualify for Council Tax Benefit and you have one or more adults who live with you, you may be entitled to a Second Adult Rebate. Your partner or a paying lodger does not count as a second adult. Your income and capital are not taken into account. The Rebate will be based on the second adults income and you may receive a reduction of up to 25% from your Council Tax. For example, if you do not qualify for Council Tax Benefit and you have no one other than a son or a daughter who is receiving Income Support living with you, you will be entitled to 25% reduction in your Council Tax. If you are a student and you have a non student(s) on a low income living with you, up to 100% reduction may apply. If you are claiming Second Adult Rebate you only need to complete Sections A, C and J of this form. 3. How to complete your claim form Please read the questions carefully, complete every section fully in black ink and tick either the Yes or No box for each question where this is required. If you do not answer a question we will have to return the form to you. You and your partner On the form we refer to you and your partner. By partner, we mean your husband or wife or the person you live with as if you were married including Civil Partnerships. If you are separated from your partner you need not complete partner details. Appointee If the claimant is unable to deal with their financial affairs, someone who has power of attorney or an assigned appointee may do so.

If you are acting as the claimant s representative, please complete the form and include your details at Section J. If the claimant has no representative but would like someone to act on their behalf for benefit purposes please contact any Service Point. Non-dependant A non-dependant is someone who normally lives in your household for example, a grown up son or daughter, or other relative. In most circumstances a deduction is made from your benefit for each non-dependant who stays with you. The amount of the deduction depends on the non-dependant s income and circumstances. If you are able to, it is important to provide a designated office with proof of each non-dependant s income, as this will allow us to make the correct deduction. If the non-dependant prefers, they can send the proof directly to any designated office. If we do not receive any proof of their income you may receive less benefit. General Counselling & Support If you are charged for certain services as a condition of your tenancy, you must let the designated office know. These would include things such as a charge for emergency alarms, cleaning rooms and windows if you are not able to do this yourself, dealing with neighbour disputes, helping you to claim benefits, shopping, helping with household budget and minor repairs. If your rent includes any of these things, tick the Yes box at General Counselling & Support in Section I on page 15 and we will get in touch with you or your landlord if we need more information. Income Disregards There are certain allowances and pensions, which are not taken into account when we work out your benefit. These are allowances such as Disability Living Allowance and Attendance Allowance. The Highland Council disregards War Disablement and War Widow s pensions. Although we disregard all of these, you must still tell us about them on the form as in certain circumstances you may get more benefit. 4. What documents do I need to send you? You must send a designated office proof of income and capital for you and your partner and proof of rent if you do not rent your house from The Highland Council. You must also send a designated office proof of income and interest received from savings for any non-dependants that live with you (see Non-dependant section above). If you do not have your payslips, we will contact your employer. If this is your first claim for Housing Benefit and/or Council Tax Benefit to The Highland Council you must provide proof of you and your partner s National Insurance Number. You must provide proof of you and your partner s identity with every claim. Examples of acceptable proof are shown on the benefit form checklist in Section L on page 20. Please try to send all the documents we ask for with the form so that we can work out your benefit quickly. If you cannot send the documents at present, send the completed form to The Operations Team, The Highland Council, PO BOX 5650, Inverness IV3 5YX right away. You then have 1 calendar month to provide the proof we have asked for. If you do not provide the proof within 1 calendar month we can cancel your claim. The quicker you provide these documents, the quicker we can assess your claim. If you would prefer, you can take the documents along to any Service Point and staff will check these and send them on to a designated office. Service Point staff will complete the checklist at Section L to confirm what proof you have provided and still need to provide. 5. When will my benefit start? You will only get Housing Benefit/Council Tax Benefit if you are occupying the property as your home. Your benefit will normally start on the Monday following the date we receive your form. If you are in receipt of Income Support (IS), Job Seeker s Allowance (Income Based) (JSA(IB)) or Employment Support Allowance (Income Related) (ESA(IR)) your benefit will normally start on the Monday after your IS or JSA(IB) starts. If you have just moved to a new address, in certain circumstances you can claim Housing Benefit on your present and previous address for a maximum of 4 weeks. If this applies to you, contact a designated office right away. We can only backdate your claim for benefit if you can show the Operations Team you had good reasons for not claiming benefit at the correct time. If you want to claim backdated benefit you must write to the designated office giving your reasons for the delay in claiming benefit. We can only backdate benefit for 6 months for working age claimants and 3 months for pension age claimants.

6. How will my benefit be paid? If you are due Council Tax Benefit or Second Adult Rebate, it will be credited to your Council Tax account. If you are a Council tenant, any Housing Benefit due to you will be credited to your rent account. If you have a private landlord any Housing Benefit due will be paid to you fortnightly in arrears paid directly into your bank/building society account by BACS or in some circumstances by crossed cheque. In exceptional circumstances we may agree to pay your Housing Benefit direct to your landlord. You would have to complete a form called a Safeguard Referral form. If you would like more information about this or to request a Safeguard Referral form please contact any designated office. 7. What if I think my benefit calculation is wrong? If you think your benefit is wrong, you can ask the Operations Team to look at your claim again. To do this, you must write within one calendar month of the date on your benefit decision letter telling the designated office why you think it is wrong. You also have the right to appeal against our decision. Our benefit appeals leaflet is available from Service Points. If you would like free advice, contact our Customer Income Maximisation Team on 0800 090 1004 or one of the voluntary agencies listed on the next page. 8. What is considered a reasonable rent? If you are exempt from Local Housing Allowance and are a private tenant we will ask the Rent Registration Service to decide if your rent is reasonable. They are responsible to the Scottish Government and are not connected to the Council. They will tell us the average rent being charged for similar sized properties in your area. This figure is the maximum Housing Benefit we can pay. If you are under 25 years of age and live alone, your rent will normally be restricted. If you would like more information about this please contact any designated office. 9. What happens if benefit doesn t cover all my rent or Council Tax? If you are likely to suffer hardship because benefit does not cover your charges in full, you can ask a designated office for a form to apply for a Discretionary Housing Payment. We will look carefully at your personal and financial circumstances and decide whether to pay you an additional payment for a fixed period of time. We have a limited amount of money to use for this purpose. 10. Can I get any other benefits? If you are on a low income you may, if you satisfy certain rules, be entitled to other benefits. There are various benefits, which make sure everyone has a reasonable level of income and the Council would encourage you to apply for these if you are entitled. If you would like more information on the benefits and other entitlements available please ask at any designated office for a copy of our guide entitled An Essential Guide to Benefits, Money Advice, Energy Advice and other Entitlements or contact our Customer Income Maximisation Team by emailing: income.maximisation@highland.gov.uk or telephone 0800 090 1004. Employment Support Allowance If you and your partner are both entitled to Employment Support Allowance please contact The Operations Team so we can advise you on who should make the claim to ensure you receive your full entitlement for Housing Benefit/Council Tax Benefit. 11. What should I do if my circumstances change? It is very important that you tell the designated office about any changes right away as these may affect the amount of benefit you are getting. If you are late in reporting a change which results in less benefit, you will have to repay any overpaid benefit. If the change results in more benefit, you may actually lose benefit if you are late in reporting this. If you know about changes in your circumstances that are going to happen in the future, let a designated office know about them now. You must tell the designated office about any changes in writing giving details of the change and the date of the change. You must also try to send a designated office any proof of the change. Some examples of changes which must be reported are: if the income or capital of any person in your household changes or stops; if you move house or move to a different room within the same house; if any person in your household starts work or changes their job; if any person joins or leaves your household; if a dependant child leaves school or Child Benefit stops; or if you are absent from your home for any reason e.g. hospital, nursing home or prison.

12. Safeguarding the Benefit system. The Highland Council would like to make sure that our customers receive the correct amount of benefit and that no one is claiming benefit they are not due. If you know of anyone who is abusing the benefit system you can telephone our fraud hotline, Freephone number 0800 854 183, so that we can make further enquiries. You will not be asked to give your name and your call will be treated in the strictest confidence. 13. Advice and Assistance The Council has a network of Service Points which are designated offices. You can contact any of these offices if you need help to complete your form or report a change in your circumstances. A list of our designated offices can be found on our website at www.highland.gov.uk Alternatively you can telephone The Operations Team on 0800 393 811. Visiting Services If you are frail, elderly or vulnerable and are unable to attend one of the Council s Service Points, our Visiting Officers are available to visit you in your home to provide advice and assistance with claiming Housing Benefit, Council Tax Benefit and Council Tax Discounts, Reduction and Exemptions. Please email: visiting.officers@highland.gov.uk or telephone 0800 393 811. Customer Income Maximisation Our Customer Income Maximisation Team can advise you about all of the benefits and other entitlements available e.g. Pension Credit, Tax Credit, Disability Living Allowance, Attendance Allowance and Disabled Parking Blue Badge Scheme, Housing Benefit, Council Tax Benefit and Council Tax Discounts, Reduction and Exemptions. If you are frail, elderly or vulnerable and are unable to attend the Council s Service Point we can complete the relevant forms on your behalf. Contact us by emailing: income.maximisation@highland.gov.uk or telephone 0800 090 1004. Money Advice and Voluntary Agencies If you are having difficulty paying and are worried about your finances, please contact our free, confidential and impartial Money Advice Service by emailing: money.advice@highland.gov.uk or by telephoning 0800 090 1004. Alternatively, you may wish to contact either your local Citizens Advice Bureau or a Local Advice Agency. Correspondence is treated in the strictest confidence. Badenoch & Strathspey Citizens Advice Bureau (01479) 810919 Caithness Citizens Advice Bureau (01847) 894243 East Sutherland Citizens Advice Bureau (01408) 633000 Inverness Citizens Advice Bureau (01463) 235345 Lochaber Citizens Advice Bureau (01397) 705311 Nairn Citizens Advice Bureau (01667) 456677 North West Sutherland Citizens Advice Bureau (01971) 521730 Ross & Cromarty Citizens Advice Bureau (01349) 883333 Skye & Lochalsh Citizens Advice Bureau (01478) 612032 Are you aware of all the benefits and other entitlements available? Pick up a copy of our Essential Guide to Benefits, Money Advice, Energy Advice and other Entitlements from any Service Point, Library or download it from our website. www.highland.gov.uk

About you and your partner - continued A YOU If you have lived at this address for less than 2 years, give your previous address. PARTNER Previous Address Postcode Dates you lived there to to At the above address state if you were a home owner, tenant or a boarder. Did you claim Housing Benefit or Council Tax Benefit there? Yes No Yes No If Yes, from which Council? Have you been incapable of work for more than 26 weeks because of illness or disability? Are you registered blind? If Yes, give registration number. Does anyone get Invalid Care Allowance for looking after you? Yes No Yes No Yes No Yes No Yes No Yes No If Yes, tell us who receives it and provide proof of this. Name Address Have you or your partner been in residential care or in hospital as an inpatient in the last 52 weeks? Yes No Yes No If Yes, give the date you went into hospital or residential care and the date you left/expect to leave, if known. In date: (Expected) Out date: In date: (Expected) Out date: Give name and address of hospital or residential home. Are you in prison? If Yes, state where. What date were you imprisoned? Yes No Yes No Give expected release date. 3

Children you or your partner are responsible for B Do you have at least one dependant child? Yes No If No go to section C. Otherwise, please complete every box for each dependant child. If there are more than 4 children, please give their details in Section K extra information. We must see proof of the child benefit you receive. This could be your child benefit book or a bank statement showing the payment. You must let us know when the child benefit stops. Surname First name(s) Date of birth What relationship are they to you? 1 st child 2 nd child 3 rd child 4 th child Do these children live with you? If any children are over 15, give the expected date they will leave school, if known. Are any of these children fostered by you? Are any of these children registered blind? Do any of these children get Disability Living Allowance? If Yes, state whether they get mobility, care or both components. Please state weekly amount. Do any of these children get Education Maintenance Allowance? Please state weekly amount. Do you pay childcare costs for any of these children? Yes No If Yes we will send you another form to complete so that you can provide the designated office with more information. Education Maintenance Allowance (EMA) To be eligible for an EMA there is one main eligibility criteria out of the four that applies which is based on date of birth. If a young adult is aged 16-19, they may be eligible for an EMA. Please tick this box if you want The Highland Council to send you more information about this. Highland Instrumental Unit (HIU) If you or your partner are in receipt of Tax Credits for the current year confirmed on HM Revenue & Customs form TC602 showing a joint income of 16,040 or less or Income based Job Seekers Allowance or Income Support they may be entitled to exemption of HIU fees. Please tick this box if you want The Highland Council to send you more information about this. 4 Clothing Grant and/or Free School Meals If you or your partner are in receipt of Income Support, Job Seekers Allowance (Income Based), Employment Support Allowance (Income Related) or Pension Credit (Guarantee Credit) and you have children at school, they may be entitled to a Clothing Grant and/or Free School Meals. Please tick this box if you want The Highland Council to send you more information about this.

Other people who live in your home C Apart from you, your partner and any children shown in Section B, does anyone else live in your home? Yes If No, go to Section D. No If Yes, please list everyone else who lives in your home, including relatives, lodgers and friends. Include all older children who you no longer get Child Benefit for. Complete every box for each person. Where specified please provide proof of income for all people shown below, as you may in certain circumstances be entitled to more benefit. They may if they wish send proof directly to a designated office. If there are more than 4 other people, please give their details in Section K extra information. Surname First name(s) Date of birth Relationship to you 1 st person 2 nd person 3 rd person 4 th person National Insurance number LETTERS / NUMBERS / LETTER LETTERS / NUMBERS / LETTER LETTERS / NUMBERS / LETTER LETTERS / NUMBERS / LETTER Are any of these people a joint tenant or a joint owner with you? Do they pay you or your partner rent? If Yes, does this include money for meals? Do they work 16 hours or more each week? If Yes, state their earnings each week before tax and National Insurance are taken off and provide proof or you may receive less benefit. Do they receive Income Support, Pension Credit (Guarantee Credit), Jobseeker s Allowance (Income based) or Employment Support Allowance (Income Related)? Do they receive Disability Living Allowance - Care Component? Lower Middle Higher Do they receive Attendance Allowance? Do they receive Education Maintenance Allowance? 5 Continued overleaf..

Other people who live in your home - continued C Please remember to complete every box for each person and where specified provide proof of income. We may contact you for further information. Enter each person s full name in same order as previous page. Do they get other state benefits? If Yes, state the benefit and the weekly amounts paid before any deductions. 1 st person 2 nd person 3 rd person 4 th person Do they get any other income not already declared? If Yes, state types of income and amounts received each week and provide proof. If they are working what was their interest from savings in the last 12 months? (provide proof, for example bank statements) Are they a student or on a training scheme? Provide proof. Are they severely mentally impaired? Are they in hospital? If Yes, give the date they went into hospital. Are they in prison? If Yes, give the date they went into prison. Are any of these people married to each other or living together as if they are married? If Yes, please state the couple s names here. 6 is the partner of is the partner of

Your and your partner s earnings D Part 1 - Employment Details. If you or your partner have more than two jobs provide all details for additional employer s in Section K. YOU PARTNER Are you self-employed? If Yes we will send you another form to complete so that you can provide the designated office with more information. Now go to next page. If No answer each question on this page. Are you currently in paid or unpaid work? If No please go to Part 2 of this section on the next page. If Yes state employer s name and address and answer each question on this page. Date you started this job. If you are on a fixed term contract, give the date the job ends. What kind of work do you do? Payroll or employee number. How often are you paid? Weekly Monthly Weekly Monthly If Other please state how often you are paid. Fortnightly Unpaid Fortnightly Unpaid 4 Weekly Other 4 Weekly Other If Unpaid please provide a letter from your employer confirming this. What is your normal take home pay? How are your earnings paid - by cheque, cash, direct to bank account or some other method? Please provide proof. How many hours do you work each week? Are you receiving: Statutory Sick Pay (SSP); Statutory Maternity Pay (SMP); Statutory Paternity Pay (SPP); Statutory Adoption Pay (SAP); or Health in Pregnancy Grant (HPG). Please provide proof. SSP SMP SSP SMP SPP SAP SPP SAP HPG None of HPG None of the above the above Give date this started. What date do you expect to return to work? Date that next pay increase is expected. 7 Continued overleaf...

Your and your partner s earnings - continued D YOU PARTNER Do you receive commission or a bonus? If Yes, state how much and provide proof. Do you pay into a pension scheme? No Company pension Private or Stakeholder pension No Company Pension Private or Stakeholder pension If you pay into a private or stakeholder pension state the amount you pay and provide proof of the last two month s payments. each each Do you have more than one job? If Yes, enter below employer s name and address for second job. Please use Section K to tell the designated office about any other employment. Name of Employer 2 Address You must provide a designated office with your last 5 weekly, 3 fortnightly or 2 monthly payslips. If you can not provide payslips, contact a designated office and we will give you a form for your employer to complete. Please note, if you fail to provide proof of earnings when submitting your claim we will contact your employer to obtain the information. Do you receive Education Maintenance Allowance? Please state weekly amount. Part 2 - Redundancy Details YOU PARTNER Have you been made redundant in the last 2 years? If No go to Section E. If Yes answer the following questions. Do you receive mortgage, loan or income protection? If Yes state the amount you receive, the date of the first payment and provide proof. First payment date: First payment date: State the date you were made redundant. Did you receive a redundancy payment? If Yes state the amount you received and when it was paid and provide proof. Date paid: Date paid: Remember to sign the declaration on page 18 and return this form within one calendar month of the issue date. 8

Other income Occupational pension, work pension, private pension and superannuation pension Occupational Pension schemes are work pensions that are set up by employers to provide income in retirement for their employees. YOU PARTNER Do you get or have you delayed getting one or more occupational, work, private or superannuation pensions? If No, please go to the section below headed Annuities. If Yes, please complete this section stating who pays each pension and how much you receive after tax. You must provide the designated office with your last two pension advice slips or your latest two bank statements showing payments. If you are receiving a pension from The Highland Council, you must tell us about it. Name and address of pension provider. E How much do you receive after tax? What date is the next increase due? Do you receive more than one pension? If Yes you must provide the same information for each pension you receive using Section K extra information. If you have delayed getting a pension, when is it due to be paid? Annuities An Annuity is an investment that provides a regular income. Do you get income from an annuity? If No go to section below headed State Pensions. If Yes tell the designated office who pays the annuity and provide proof. Do you get more than one annuity? If Yes you must give the designated office details of all other annuities in Section K extra information. State Pensions Do you receive any of the following pensions? If Yes please enter amount before any deductions and state how often they are paid, e.g. weekly, fortnightly, 4 weekly or monthly. Please tick either Yes or No box on each line. You must provide proof for each pension, for example a social security letter of award or your last two bank statements showing payments. Yes No YOU Yes No PARTNER Retirement Pension Widow s Pension War Widow s Pension War Disablement Pension 9 Continued overleaf..

Other income - continued E Benefits and Allowances Do you receive any of the following? If Yes please enter the amount before any deductions and state how often they are paid, e.g. weekly, fortnightly, 4 weekly or monthly. You must tick either the Yes or No box on each line. Where specified you must provide a designated office with proof for each benefit or allowance, for example your DWP award letter or your last two bank statements showing payments. YOU PARTNER Income Support Employment Support Allowance (Income related) Employment Support Allowance (Contribution) Pension Credit (Guarantee Credit) Pension Credit (Savings Credit only) Jobseeker s Allowance (Income based) Jobseeker s Allowance (Contribution based) At which Jobcentre Plus do you sign on? Child Tax Credit Working Tax Credit Incapacity Benefit: short-term lower short-term higher long-term Attendance Allowance Provide proof for the following Benefits Widowed Mother s or Widowed Parent s Allowance Child Benefit Maternity Allowance Fostering Allowance Guardian s Allowance Return to Work Credit Self-Employment Credit Industrial Death Benefit Industrial Injuries Disablement Benefit Bereavement Allowance 10

Other income - continued E Benefits, Allowances and other sources of income Please remember to tick either the Yes or No box on every line and answer every question. You must provide a designated office with proof for each benefit, allowance or other source of income on this page apart from Disability Living Allowance. Yes No YOU Yes No PARTNER Disability Living Allowance, mobility component: lower rate higher rate Disability Living Allowance, care component: lower rate middle rate higher rate If you receive any of the benefits, allowances or other sources of income below you must provide a designated office with proof. Do you have a motobility car? Care Allowance Severe Disablement Allowance Training Allowance Maintenance payments you receive Income from letting a room or property Payments from a charity Do you have any other income not already declared? If Yes, please give details. Have you claimed Invalid Care Allowance but are not getting it because you get another benefit? If Yes, please provide proof of this. Have you applied for any other benefits or income but have not yet received them? If Yes, please tell a designated office which benefits or income and the date you applied for them. Benefit or income Benefit or income Date applied for Date applied for Benefit or income Benefit or income Date applied for 11 Date applied for

Capital - cash, savings, property, land and investments F Do you have any of the following? Answer either Yes or No to each question. If Yes, enter the amount currently held even if under 10,000. You must provide recent proof of your own and your partner s savings, property, land and investments if the total value is 6000 or over if you are under 60 or 10,000 or over if you are 60 or over. Please refer to the checklist at Section L to find out what we will accept as proof. If you do not have enough space for all your capital details, please use Section K. YOU PARTNER Yes No Total held Yes No Total held Cash savings Current account Deposit account Building Society account Post Office or Giro account Lump sum payment of State Pension Please give any bank, building society and post office details below. Name of bank, Name of Type of account Account numbers building society or post office account holder(s) Income Investment Bonds Premium Bonds National Savings Bonds National Savings Certificates Yes No Total held Yes No Total held Please give Income or Investment Bonds, Premium Bonds, National Savings Bonds, National Savings Certificate details below. Type of Bond or Certificate Date of purchase Number of units held Issue number Stocks, Sharesave, Shares or Unit Trusts Yes No Total held Yes No Total held Please give any Stocks and Shares details below. Name of company Number of stocks Name of company Number of stocks or shares held or shares held 12 Continued overleaf..

Capital - cash, savings, property, land and investments - cont. F You must provide recent proof of your own and your partners savings, property, land and investments if the total value is 6,000 or over if you are under 60 or 10,000 or over if you are 60 or over. Do you or your partner have an ISA? Yes No If Yes, give details. Do you or your partner own any property, timeshare or land in this country or abroad other than the house you live in? Yes No If Yes, give address of the properties or land and provide proof of ownership. Estimated value of this asset We may contact you for more information Do you or your partner have any other cash, savings or investments, or money owing to you which you have not already declared? Yes No If Yes, give details. If you have more than one capital asset, we need the same details for each asset. If you do not have enough space use Section K. Money paid out Do you or your partner help to support any of your children who are full-time students attending college or university? Yes No If No, go to Section H. If Yes, state how much you contribute annually and provide the students award letter with this form. G Students H If you have already provided all of this information for Council Tax purposes you will not have to provide it again. Full time students can only get Housing Benefit in special cases. Please contact the Operations Team if you would like more information. YOU PARTNER Are you a Student or Student Nurse? If No, go to Section I. If Yes, complete the questions below and provide proof with this form unless you have already provided all of this information for Council Tax purposes. Are you a full-time or a part-time student? Full Part time time Full Part time time Is your course under the New Deal? Give start and end date of current year. If you receive a student loan, bursary or grant, insert amount. Start End Start End Loan Bursary Grant Loan Bursary Grant 13

Private rent details I You should only fill in this section if you pay rent to a landlord other than The Highland Council. If you are a Council tenant or an owner occupier, go to Section J. You must provide a designated office with your signed tenancy agreement or other written evidence of your rental agreement from your landlord or landlord s agent. Give the date If your landlord has an agent acting on their behalf your tenancy please complete the agent s name, address and started. telephone number as well as the landlord s details. Landlord s Surname Landlord s first name Address Agent s Surname Agent s first name Address Business address if different from above Telephone number Email address Business address if different from above Telephone number Email address Who owns the property you live in? Are you, your partner or any of your children related to the owner? Yes No If Yes, say what the relationship is. Are you or your partner related to your landlord or your landlord s partner? Yes No If Yes, say what the relationship is. Are any of your children related to your landlord or your landlord s partner? Yes No If Yes, say what the relationship is. Do you or your partner live in the same property as your landlord? Yes No Have you or your partner previously applied for Housing Benefit at this address? Yes No Was your last tenancy with the same landlord? Yes No Do you or your partner have a written tenancy agreement? Yes No Has your rent been registered as a fair rent by the Rent Officer? Yes No Don t know What amount of rent are you liable to pay? each How often do you or your partner pay rent? Weekly 4-Weekly Calendar monthly Other If Other, state frequency. Do you have any rent free weeks? Yes No If Yes give details State who you make your rent payments to? 14 Continued overleaf..

Private rent details - continued I Are you a joint tenant? Yes No If Yes, please give the names of all other joint tenants and state how much your share of the rent is. every Direct How do you pay your rent? Debit Cash Cheque Standing Order Other If Other, give details. Are you in arrears with your rent? Yes No If Yes, how much? If your rent includes money for any of the following, tick either the Yes or No box, fill in the amount you pay and state how often you pay it. Does your rent include money for: Yes No Don t know State Amount (if known) Heating each Lighting each Hot water each Cooking facilities each Laundry facilities each General counselling and support each (see Guidance Note 3) Cleaning each Emergency alarms each Water and sewerage each Other services (give details below) each each each What type of tenancy do you have? Regulated Assured Short Don t Other Assured Know If Other, give details. Is your accommodation centrally heated? Yes No Do you have a garage attached to the house? Yes No Is your tenancy for a set period of time? Yes No If Yes, state when your tenancy ends. Is your accommodation let as: Fully furnished Partly furnished Unfurnished Who is responsible for internal decoration? Me Landlord Don t know Are any meals provided? Yes No If Yes, tick each box that applies Breakfast Lunch Evening meal All meals 15 Continued overleaf..

Private rent details - continued I Please remember to answer every question Tick each box which best describes your accommodation. Detached house Semi-detached house Terraced house Detached bungalow Semi-detached bungalow Terraced bungalow Detached cottage Semi-detached cottage Terraced cottage Tenement flat Flat over commercial Flat in house premises Hostel Static caravan Touring caravan Room Other If Other, give details. Do you have any of the following, please tick each box that applies. Garage Garden Car Parking (off road) State number of floors in the whole building including ground floor. Tick which floor(s) your accommodation is on? Ground 1 st floor 2 nd floor 3 rd floor 4 th floor All If you live in a single room, which part of the property do you live in? Front Middle Back What is your room number? Living rooms Bedrooms Bed-sitting rooms Kitchens Bathrooms Separate toilets Other rooms Please specify other rooms State number of rooms State number of rooms used State number of rooms shared in whole building only by you or your family with your landlord or others If you share one bedroom or bed-sitting room, please state the number of people sharing that room and give their names. Number sharing Names 16

Private rent details - continued I Sharing Information with your Landlord Sharing information with your private landlord could help the Operations Team deal with your claim more quickly and reduce the risk of you falling behind with your rent because of your claim being delayed. We may need to confirm information with your landlord before we can make a decision on your claim, for example, the start date of your tenancy. In these circumstances, we can contact your landlord without your permission. Under the Data Protection Act 1998 we need your permission to discuss anything else. If you give your permission, we would be able to tell your landlord whether: you have claimed Housing Benefit; or we have made a decision on your claim; or we need more information to make a decision on your claim, and what that information may be. We will not give your landlord any information about: your personal or household circumstances; or your financial circumstances. You can withdraw your permission at any time. It will not affect your claim if you do not give your permission to discuss your claim with your landlord. If you want to give your permission to discuss your claim with your landlord, please sign below. I give The Highland Council s designated offices permission to share information about the progress of my Housing Benefit claim with my landlord or their representative. Signature Date Full name and address of landlord/ representative (in CAPITAL LETTERS) Postcode Direct Payments to Landlords - Their Responsibilities If your Housing Benefit is to be paid directly to your landlord, you must ask him/her to read and sign the statement below. If your tenant s Housing Benefit can be and is paid directly to you, you must agree to inform The Highland Council s designated offices immediately you are aware of any changes in your tenant s circumstances, e.g. if your tenant moves out of the property, even if still liable for rent. We expect you to make regular checks to confirm that your tenant is still living at the property where you are receiving Housing Benefit payments. Landlord s Signature Date Remember to sign the declaration on page 18 and return the form within one calendar month of the issue date. 17 Continued overleaf..

Payment of Housing Benefit into Bank/Building Society accounts If you are entitled to Housing Benefit, we will pay it straight into your Bank or Building Society Account. Please give a designated office your Bank or Building Society details below; Bank or Building Society name and address Account Holders Name Account Number Sort Code - - Declaration - all applicants must complete this section J Please read this declaration carefully before you sign and date it. Warning: It is an offence to give false information. If someone has completed this form on your behalf, you must make sure that it has been read back to you in full and you understand everything before you sign the declaration. In the case of a couple, only the claimant must sign the form below. This is my claim for Housing Benefit, Council Tax Benefit, Second Adult Rebate. I declare that the information I have given on this form is correct and complete. I have read and understood the guidance notes included with this form. I authorise the Council to check the information I have given and make any necessary enquiries to verify the information on this form and retain a copy. I understand that the information that I have given on this form may be held electronically and may be shared with other Council Services and relevant agencies, or used when considering a discretionary housing payment. I understand that if I give information that is wrong or not complete or fail to report a change which may affect my benefit I may be prosecuted. See Guidance Note 11 for examples of changes in circumstances. Claimant s signature Date Remember to complete the checklist on page 20 and return this form as quickly as possible. This section must be completed if the claim form has been filled in by someone else on your behalf. This includes voluntary organisations, an appointee, relative, friend or representative of the Council. Please print the name of the person who completed the form Their address Their telephone number Email address Relationship to claimant or partner if any Please give the reason why the claimant was unable to complete the form I declare that I have filled in this form for the person(s) named above in accordance with their instructions and have read this back to them in full before they signed the declaration. Signature of person Date completing form 18

Extra information K Use this section to give information that may help a designated office work out your benefit. State which page number and section your notes relate to. Continue on a separate sheet if necessary. Equal Opportunities Statement The Council is committed to fulfilling its duties to promote equality and to tackle discrimination and disadvantage - as an employer, in providing public services, in community leadership and partnership working. We aim to ensure our employment and recruitment practices are fair and that our services are accessible, and we will work to ensure that no-one is disadvantaged because of their age, disability, faith, gender, race, sexual orientation or social background. How we collect and use information We will use the information you give in this form and any supporting proof you send the designated office, to process your claim for Housing Benefit, Council Tax Benefit and Second Adult Rebate. The Highland Council is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud and to make sure that the information is accurate. We may also share this information with other Council Services, Agencies, Organisations, Local Authorities, Government Departments and other bodies responsible for auditing or administering public funds. We will not give information about you to anyone else, or use information about you for other purposes, unless the law allows us to. The Highland Council is the data controller for the purposes of the Data Protection Act 1998. If you want to know more about what information we have about you or the way we use that information, you can email foi@highland.gov.uk or write to the Information Manager, Chief Executive s Office, The Highland Council, Glenurquhart Road, Inverness, IV3 5NX. The Council would like to make sure you are claiming all the benefits to which you are entitled and we may use the information given to check if you are due other state benefits. If you do not wish it to be used for this purpose, please tick this box. 19

Checklist L Please use this checklist to tell a designated office what proof you are sending with the form. Use Section K if you need more space. We must see original documents only as copies cannot be accepted. We may not be able to pay you any benefit until you give a designated office the proof we ask for. We need the same proof for your partner, if you have one. To avoid losing benefit you should fully complete, sign and return this form complete with all of the required information and proof requested as quickly as possible. You have up to 1 calendar month to provide a designated office with everything else we ask for. Do not send valuable items like passports through the post. If you can, take them to any Council Service Point and we will copy them and return them to you straight away. If you are not able to provide proof and can not visit a designated office, please telephone the Operations Team for advice. See Guidance Notes, Section 4. Proof That You Must Provide 1 Proof of your identity Such as benefit award letters, birth certificate, marriage certificate, current passport, driving licence, National Insurance Number card, recent telephone, gas or electricity bills. We need to see different types of these documents for both you and your partner. Type Enclosed To follow of Please Please evidence tick tick 2 Proof of savings, capital, investments if the total value is 6,000 or over if you are under 60 or 10,000 if you are 60 or over Such as your bank, building society or post office books, certificates for premium bonds, details of any land or property, National Savings Certificates, ISAs, annuities, stocks, shares, unit trusts and bank statements covering the last two months. Your bank books and statements should show the up to date balance. 3 Proof of earnings We need to see your and your partner s last 5 payslips if you are paid weekly, last 3 payslips if you are paid fortnightly, or your last 2 payslips if you are paid monthly. If you do not have these, or if you have just started work, we will contact your employer. 4 Proof of rent to a private landlord and tenancy details Such as your tenancy agreement, a rent book, rent receipts or a letter signed by your landlord. 5 Proof of other income For example if you get a pension from a former employer or from a private source, we need to see your last two pension slips or last two bank statements showing how much you are paid. If you receive maintenance payments we must see a letter from the court or some other proof. 6 Proof of income for Non-Dependants (See guidance notes 3). See 3 above for what proof of earnings we require. If they are working we also require proof of any interest received on savings such as their latest bank, building society or post office books or statements. 7 Proof of other money paid out Such as student grant letter of award or parental contribution agreements. If this is your first claim for Housing Benefit and/or Council Tax Benefit to The Highland Council you must also provide the following: 8 Proof of National Insurance Number We need you to confirm your National Insurance Number allocated to you and your partner. This will be shown on your payslips, benefit award letters, National Insurance Number card. Remember - we must see original documents. 20 For Office Use Only Date checklist copied and given to customer: Signed: / / Date Benefit form copied and original given to customer: Office: / /......