How Accurate Is the Benefit Check?

Benefit Check Form

Complete this form as fully as possible. We will then check those welfare benefits to which you appear entitled. How accurate is the benefit check? This depends on you! If you give us full, correct answers to our questions, we will give you a good estimate of your benefit entitlements. However, actual entitlements can only be decided following receipt of a claim/application made on the appropriate claim/application form. How you can help us

To enable us to check you are receiving the benefits and tax credits to which you are entitled, please include or send with this form, the following information for everyone living in your home. (we will copy and return to you any original documents you send)  Dates of birth  Employment status (including whether employed or self-employed)  Number of hours worked  Gross income from employment for last tax year – April 6 to April 5 (A P60 form will provide this, or if self- employed, last year’s accounts)  Gross income for this year. Pay slip is preferred. Estimate if self employed  If you are receiving benefits at present, please bring all the benefit award letters  Child care costs. Please bring something to show that the carer is fully approved along with how much you pay them  Investment income. Details of investments and latest interest payments. Bank statements may be the best way to show this  Rental agreement or current mortgage repayment  Council tax bill

For office use only:

Date issued: / / Client Name...... Ref Number: RC..../......

Date received:...... Form and attachments checked by:......

Scanned to CASTLE Record by:......

For attention of: GEN/WR/MA . Why we need you to complete this benefit check form We use the details you give us to estimate what benefits we think you (and your partner, if appropriate) should be receiving. Then, if you want, we can help you to claim any extra benefits, which we identify for you. . What we do with your personal details – Data Protection We are subject to the Data protection Act 1998 which means that we will treat any information you give us as sensitive information. Everything that you tell us will be treated in the strictest confidence. We apologise in advance for the personal nature of many of the questions, but, we do need all of the information to provide you with a reasonably accurate benefit check. (Your signature/s on the next page provide your acceptance of this information)

. Please tick just one of the boxes below: I am completing this form. Please check my benefits. (Please complete all pages from page 3 onwards)

I need help with this form. (Please complete your name and address on page 3 and bring or send this form back to us. We will then make an appointment with an adviser, who can try to help you)

Alness Bureau Dingwall Bureau Suie House, Market Square, Alness, IV17 0UD 4 Church Street, Dingwall, IV15 9SB Opening Hours Monday: 10am – 2pm (Appointments Only) Closed Tuesday: 10am – 2pm (Drop-in +Appointments) 10am – 2pm (Drop-in) Wednesday: 4pm – 7pm (Appointments Only) Closed Thursday: 10am – 2pm (Drop-in) 10am – 2pm (Appointments Only) Friday: 10am – 2pm (Drop-in) 10am – 2pm (Drop-in) Telephone: 01349 883333 01349 864850 Fax: 01349 884126 01349 860102

Tain Bureau Invergordon Outreach 1 & 2 Market Street, Tain, IV19 1AR 51-55 High Street, Invergordon, IV18 0DG

Opening Hours Tuesday: Thursday: 10am – 12 noon (Drop-in) & 10am – 2pm (Drop-in) 2pm – 4pm (Appointments Only) Telephone: 01862 892426 01349 883333 Fax: 01349 884126 01349 884126

E-mail: [email protected]

www.rossandcromartycab.org.uk Ross & Cromarty Citizens Advice Bureau (Ross and Cromarty CAB), SCO 14736, is a Registered Scottish Charity. Registered Company No. 176909. Page 2 About you Surname: Signature: First name:

Title: Mr / Mrs / Miss / Ms / Other (Please state):

Address:

Postcode:

Status: Single / Married / Partnered / Widowed / Separated

Nationality: …………………………………………………………………….

Date of birth: / /

National Insurance Number: [ ] [ ] [ ] [ ] [ ]

Telephone Number: Home:……………………………………….. Mobile:……………………………………….

E-mail: N.B.: We will not transmit nor will we recommend transmission of sensitive data using the email system.

Do you have a spouse or partner who lives with you? Yes No

(If you ticked yes, please complete the next section ‘About your partner’.) About your partner

Surname: Your partner’s signature: First name:

Title: Mr / Mrs / Miss / Ms / Other (Please state):

Nationality:

Date of birth: / /

National Insurance Number:

More about you and your partner Which of the You Your partner following best describes:- Do not have a job Have a job or are off sick from work Have a job but are on maternity leave On a Government Training Scheme Full-time student (Have you discussed your situation with your Yes No Yes No College administration or student’s union?

Have either you or your partner moved to Yes No Yes No the UK from abroad?

If yes, when did you come to live in the UK? / / / /

Are you or your partner sick or disabled? Yes No

If yes, please state which of you is? ______for how long? ( Please tick one box) less than 6 months

between 6 months and 1 year

more than 1 year

Do you or your partner look after a disabled Yes No person?

If yes, please state which of you does? ______Is this for more than 35 hours a week? Yes No

Who is the disabled person? ______

Does this disabled person receive Yes No attendance allowance, constant attendance allowance or disability living allowance care component at the middle or higher rate?

Is anyone receiving carer's allowance for Yes No looking after this disabled person? Page 4

About children and young people who live with you Please give details of children and young people in your family under 18 years of age. Count only your own and your partner’s children. Also, give details of anyone aged 18 or over for whom you or your partner still receives child benefit. How many children and young people are there?: ______Names of children and young people: Dates of birth: Male or Female: ______(If more than 4, continue on back page) Do you receive child benefit for all of these? Yes No

If no, please state for which child or young person child benefit is not received: Name(s): Are any of the children or young people registered Yes No blind? If yes, please give the name(s): Name(s): Do any of the children or young people receive Yes No disability living allowance? Does it include the highest rate care component? Yes No

If yes, please state child’s or young person’s name(s):

Do any of the children or young people have savings Yes No over £3000? If yes, please state child’s or young person’s name(s) and total value of the savings: Name(s): £ Do you pay someone to look after your children? Yes No

What is the weekly amount?: In term time £______During holidays £______

Who provides the care? ______. NB We may need to contact you for more information. Page 5

About all other children and young people who live with you Are there any children or young people under 18 years Yes No of age living with you (such as those belonging to a daughter, son, or lodger) not already mentioned? Names of these other children and young people: Dates of birth: Male or Female: ______About all other people, aged 18 and over, who live with you (Include young people aged 18 and over for whom you no longer receive child benefit.) How many other people, aged 18 and over, live with you? (do not count your partner and children already mentioned) ______

1. How many of these are boarders or lodgers, who pay rent to you or your partner? ______How much weekly rent do they pay to you or your partner? £______

2. Of the rest, how many are students or student nurses? ______

3. Of the rest, how many receive pension credit? ______

4. Please give the following information for those not included in the above numbers: (Identify those living together as a couple) Age Type of Income NO of Weekly Gross Hours Worked Weekly Earnings ______£ ______

______£ ______

How many receive attendance allowance or the middle or highest rate of the care component of disability living allowance / personal independence payment or are registered blind? ______Page 6

About benefits that you or your partner receive now If you or your partner are currently receiving income support or pension credit, you will find the benefit award letter useful. It will list most of your benefits. To help us, please enclose a copy of the award letter(s) with this form. To help with this page, here is a checklist of most common old and new benefits: Attendance Allowance Jobseekers Allowance (Contributions Based) Carer's Allowance Jobseekers Allowance (Income Based) Child Benefit Local Housing Allowance Child Tax Credit Maternity Allowance Council Tax Reduction Pension Credit Disability Living Allowance (Care) Personal Independence Payment Disability Living Allowance (Mobility) Second Adult Rebate Employment and Support Allowance Severe Disablement Allowance (Contributions Based) State Retirement Pension Employment and Support Allowance (Income Statutory Maternity Pay Based) Statutory Sick Pay Housing Benefit Universal Credit Incapacity Benefit Working Tax Credit Income Support

Benefit Paid To Amount How Often (Self /Partner) (Weekly / Fortnightly 4-weekly / Monthly)

______£ ______

About earnings Note: The tax year runs from 6th April of one year to the 5th April of the following year Earnings for this current tax year: You Your Partner

Yes Yes No No Do either you or your partner work?

What type of work do you do?

Normal hours worked per week:

Normal gross wage before income tax and national insurance deductions (please provide copies of £ £ your latest two pay slips):

Normal pension contributions deducted from this £ £ gross wage:

How often is this gross wage paid? every:

Earnings for the previous full tax year: Tell us about all jobs that you had. Use the back page for more space. (Forms P60 should be supplied). You Your Partner

Did either you or your partner work? Yes No Yes No

What type of work did you do? Normal hours worked per week: Normal gross wage before income tax and national £ £ insurance deductions: How often was this gross wage paid? every: If you or your partner worked last year, did either of you receive any social security benefits?

If you did please tell us: What type of benefit it was / How much was paid / How often it was paid / What period it was paid for: ______

If you have changed employers, or have had periods of unemployment, in the last couple of years, please list all the dates on which your circumstances changed (use the back page if necessary): Page 8 About savings You Your Partner

Do you or your partner have any Yes No Yes No savings?

Cash / Bank / Building Society savings: £ £

Lump sum redundancy payment: £ £

Saving certificates: £ £

Shares: £ £

Other (give type): ______£ £

Do you or your partner own property or land Yes No Yes No other than the place where you live?

About personal pensions You Your Partner (not state retirement pensions)

Gross personal pension received: £ £

Net personal pension received: £ £

How often is this pension paid? every: About any other income you or your partner receive

Please give details of any other income which you or your partner receives such as maintenance payments and payments from charities. Tell us: What type of income it is / How much is paid / How often it is paid / Who it is paid for / Who it is paid to: ______

About the rent for your home - (if owned, go to next page) Who do you and your partner rent your accommodation from? Council Housing Association Private Landlord

When did your and your partner’s tenancy begin? / /

How much is the contractual rent for this tenancy? £ Do you and your partner already claim housing benefit? Yes No If yes, when did this claim begin? / /

How much housing benefit is paid weekly? £ How often should this rent be paid? Every: Week Month

Does this rent include any amount for fuel, water or Yes No council tax? If yes, what is the total amount? £ Does this rent include any amount for care, support or Yes No supervision provided by your landlord? If yes, what is the total amount? £ How many weeks per year are rent free? More about the size of property rented Do you and your partner share the rent with anyone else? Yes No

Is your home: A house A flat A bedsit Or______

. Please tell us about the Numbers of each type of room in your home. . Then tell us how many rooms are for your own use: (this means used only by you, your partner and the people that you told us about on pages 4 and 5.) . Then tell us how many rooms are shared with other people in the building. Living Rooms Bedrooms Kitchens Bathrooms Toilets . Number of: . For own use: . Shared:

Are you under 22 years old and in the past have been given Yes No somewhere to live by Social Services

Are you under 22 years old and, since you were 16, have at some time Yes No been in the care of Social Services. Page 10

About your owner occupied home (You will find your last mortgage(s) account statements will help you here) Is it owned?--> By you Your partner Both With others

Do you have?--> a mortgage (And/Or) home improvement loan On what date did mortgage/loan start?--> / / Are you and/or your partner responsible for all of it? Yes No

If not, how much? All Half Two-thirds Other ______What was the original amount borrowed? £ How much of this original amount is still owed? £ How much of the amount still owed is arrears? £ If you receive income support, when did your claim start? / / About your council tax (You will find your council tax bill or benefit award letter will help you here)

NB: Council Tax Reduction (CTR) replaced Council Tax Benefit (CTB) on 1st April 2013. CTR can reduce your liability to Council tax. It is no longer considered a welfare benefit.

Are you or your partner responsible for council tax? Yes No How many other people share responsibility for this council tax (do not count your partner)? ______What is your council tax band? A B C D E F G H Do you and your partner already claim Council Tax Reduction? Yes No

Now, please turn to the back page and complete it before sending this form back to us. Use this space for any imminent change of circumstances: Page 11 Have you remembered? To include the documents (or photocopies) of items listed below.

Income Support Letter of Award Recent Pay slips

Pension Credit Letter of Award Tax Credit Letter of Award

Employment & Support Allowance Letter

Housing Benefit Letter of Award

Council Tax Bill or Benefit Letter of Award

All P60 Statements of Earnings How many P60’s?

We hope that you have found this form easy to complete. If you have not, we would like to hear about any problems that you have had with the form. If you can spare the time, please tell us about those problems in the box below: Use this box for anything else that you wish to tell us:

or you can let us know by using our contact details on the front of this form. Please date the form below and then send or bring it to one of our offices (details are on the front of this form). When we receive it, we will run a benefit check for you and your family. You will receive a copy of the results in the post. Date: / / BC1: Benefit Check Form: Version 10-4.1; LW-23-7-2014