Application for Discretionary Housing Payments (DHP’s) Name: Address:

Bolsover District Council The Arc High Street Clowne Ref. Number: Derbys S43 4JY Telephone number: Tel: 01246 242436 Email: Email: [email protected]

We would like to assess your claim as promptly as possible, therefore please provide the details requested above so that we can make contact with you. If you would prefer that we deal with a representative in order to speed up the processing of your claim please provide their details below: (Please note, providing their details means that you are giving your consent for us to discuss your personal finances with them)

Representative’s name:

Representative’s relationship to you: (Family member, social/care worker, advice agency etc)

Representative’s contact details: (Telephone number) Please use this form to claim for Discretionary Housing Payments (DHP’s). Please provide as much information as possible, along with the recommended supporting evidence, as this will be used when we are considering your claim. Should you require assistance in completing this application form please contact us on 01246 242436. Please note that DHP’s can only be considered for person’s eligible to receive Housing Benefit. If you do not/would not qualify for Housing Benefit you will not be eligible for Discretionary Housing Payments. In order to determine your eligibility we will need to ask questions and see evidence of your income and expenditure. Please note that this may involve you answering questions about your personal finances, which some people may find intrusive, however in order to determine your eligibility answering the questions and providing the required evidence is necessary. Please be prepared to provide this information from the outset when deciding if you would like to apply for DHP’s. Below is a list of possible items of expenditure, and examples of the supporting evidence that we will require, that you may have on a weekly basis. Please tell us about how much you spend on those items and provide proof where possible. Housing Costs Rent £ : Per week Water Charges £ : Per week

Ground Rent £ : Per week Gas £ : Per week

Social Fund Loan £ : Per week Household Insurance £ : Per week

Other Loan or HP £ : Per week Contents Insurance £ : Per week

Council Tax £ : Per week Repairs £ : Per week

Telephone £ : Per week Electricity £ : Per week (House telephone) Housekeeping Food £ : Per week School Dinners £ : Per week

Toiletries £ : Per week Cleaning Materials £ : Per week

Health Expenses £ : Per week Newspapers £ : Per week

Pocket Money £ : Per week Entertainment £ : Per week

Cigarettes £ : Per week Pet Food £ : Per week

Alcohol £ : Per week Holidays £ : Per week

Clothing £ : Per week Other £ : Per week e.g. ………………………. Car Road Tax £ : Per week Insurance £ : Per week

Petrol £ : Per week Repairs £ : Per week Public Transport Fares to Work £ : Per week Fares to School/College £ : Per week

Fares to Shops £ : Per week Other Fares £ : Per week Please explain ……………….. Other Maintenance £ : Per week Insurance £ : Per week

Life Assurance £ : Per week Subscription TV £ : Per week (e.g. Sky, Virgin Media etc) TV Rental £ : Per week TV Licence £ : Per week

Broadband/Internet £ : Per week Monthly subscriptions £ : Per week (e.g. Netflix, lovefilm.com, gym memberships etc) Mobile Telephone £ : Per week Other £ : Per week e.g. ……………………….

Examples of the types of evidence you should provide in support of the above include:

 Utility bills  Receipts for purchases/petrol  Copies of invoices  Bank statements showing your direct debit payments e.g. Motor insurance payments  Loan agreements  Receipts for weekly pre-payment card top-ups i.e. mobile phones, electricity and gas.

Please note that the above list is not exhaustive. Please provide any evidence that you feel is relevant to support the breakdown of expenditure that you have listed above.

If you would like for your details to be passed over from the Benefits Department to Bolsover District Council’s Housing Team please tick the box below. The Housing Team can look into alternative Housing or funding options and provide you with Housing options advice if you are struggling to meet your rental liability.

I confirm that I am happy for my details to be passed over to the Housing Team

Please confirm the weekly amount of income (ignore any boxes that are not applicable). Proof of the income amounts quoted may be requested if we are unable to verify them against the information already held on file for you.

Income from your Benefits/Allowances £ : Per week Income from your Partner’s Benefits/Allowances £ : Per week Income from your employed earnings £ : Per week Income from your Partners employed earnings £ : Per week Income from your Pension £ : Per week Income from your Partners Pension £ : Per week Child Benefit £ : Per week Maintenance Received £ : Per week Income from non-dependant or sub-tenant £ : Per week Any other income £ : Per week

Additionally, please answer the following questions in as much detail as possible. The more information that you provide at this stage will reduce the need to ask further questions at a later date. This may help speed up the decision making process. Q1 – If you are a Private tenant have you contacted your Landlord to try and negotiate a lower rental charge? (Please provide details of your Landlord’s response to your request if this is the case)

Q2 – Please advise if you are currently in rent arrears? (Please provide proof of your rent arrears and any subsequent action taken by your Landlord)

Yes No Amount (if applicable)

Q3 – Please advise if you currently have any outstanding debt?

Yes No (Please advise details below) (Please proceed to Q4) (Please continue on a separate sheet if necessary)

Type of Debt Company name Original Debt Amount Amount Outstanding Repayment terms

NB – Please provide evidence of any of the details that you have listed above. Q4 – Have you taken any measures to reduce your expenditure?

Yes (If you have answered yes please clarify what action has been taken)

No (If you have answered no please advise the reasons why you have been unable to take measures to reduce your expenditure) Q5 – Please advise what actions you have taken, or are about to take, to try and improve your financial situation? (e.g. seeking work, finding cheaper accommodation, reducing your expenditure (i.e. ending monthly subscription contracts such as pay TV or mobile phones or sourcing cheaper utility providers) or investigating the possibility of additional benefit entitlement (e.g. Tax Credits or Carer’s Allowance)

NB – Please continue on a separate sheet of paper if necessary.

Q6 – If you are in receipt of Disability Living Allowance care and/or mobility (or any other Disability Benefit) please provide a breakdown of any expenditure you have for health related needs that has not already been included within any of the sections above.

Please, using the space provided below, tell us about the reason or reasons why you feel you should be awarded Discretionary Housing Payments. It is very important that you give us as much information as possible. Please continue on a separate sheet of paper if necessary. If it is decided that you are entitled to Discretionary Housing Payments they will only be awarded for a limited period of time. This is to allow you time, if you are able, to make changes to improve your financial situation. Should you consider that you are still struggling to meet the shortfall between your Housing Benefit and rental liability, after this initial period of time, you can submit a new application for DHP’s.

Finally, please read and sign the declaration below. I declare that the information given on the form is true and complete. I authorise the Council to check the information if they wish to do so.

I understand the following:

 You will use the information I have provided to process my claim for Discretionary Housing Payments. You may check some of the information or update my records with other council departments, rent offices, other councils and government organisations.  You may use any information I have provided in connection with this and any other claim I have made or may make in the future. You may give this information to other government organisations if the law allows this.  I know that I must let you know about any changes (or changes in respect of persons living within my household) to my income or expenditure that might affect my claim. I know that I must let you know about any changes as soon as I know about it. I understand that all personal information provided to Bolsover District Council will be held and treated in confidence in accordance with the Data Protection Act 1998. It will only be used for the purpose stated in the declaration above, and by law we may pass your personal information to other local authorities, government departments and agencies to prevent and detect fraud, corruption, money laundering and other crimes. We may share your information with a named representative where this has been requested by you and we have signed authority to do so. All information held by this Council falls within the scope of the Freedom of Information Act 2000. We could receive a request for information held within your application. However, an exemption exists to protect the disclosure of personal information which would breach the Data Protection Act 1998. Where a DHP claim has been received, the Council will notify you of the DHP decision in writing and with reasons as soon as it is reasonably practicable.

Your Signature: Date: