Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 1
PPhone:hone: 0 165601656 64339 6436436 Bridgend County Borough Council TTeextxt R relay:elay: 1 818001001 (0 1(01656)656) 64 3643643643 PO Box 107 EEmail:mail: b enefiEtsH@QHb¿riWdVg#enEdU.LgGoJvH.uQkGJRYXN Bridgend WWebsite:ebsite: w wwZ.ZbrZidgEeULnGdJ.gHoQvG.uJk RYXN CF31 1WB
Name: Reference number: Address:
Date issued: / / Postcode: 'DWHRI¿UVWFRQWDFW
Claim &foODrLmP IfRoUrP HIoRUu+sRinXgVL QBJe%nHeQfiHt¿, WL/oRcFaDlO H+oRXuVsLQinJg$ AOORllZoDwQaFHnc&eR, XCQoFLuOn7Dc[il5 THaGxX FRWLeRdQu ction, IUHHVFKRROPHDOVDQG'LVWLQFWLYH6FKRRO8QLIRUP*UDQW free school meals and Distinctive School Uniform Grant
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+RXVLQJ%HQH¿W is help towards paying towards your rent if you rent your home from a housing association or do not qualify for Local Housing Allowance (we will check this for you).
/RFDO+RXVLQJ$OORZDQFHLVDUDWHWKDWZHXVHWRZRUNRXW+RXVLQJ%HQH¿WIRU\RXZKHQ\RXUHQW\RXUKRPH from a private landlord.
&RXQFLO7D[5HGXFWLRQ is help towards paying your council tax bill.
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Please answer all the questions by ticking either ‘Yes’ or ‘No’ and giving more details when we ask. If you GRQRWDQVZHUDOOWKHTXHVWLRQVZHZLOOKDYHWRZULWHWR\RXWRDVNIRUWKHLQIRUPDWLRQZKLFKPLJKWGHOD\ \RXUEHQH¿W
,IWKHUHLVQRWHQRXJKURRPRQWKHIRUPIRU\RXWRZULWHHYHU\WKLQJWKDW\RXQHHGWRSOHDVHZULWHLQWKH space in section 12 at the back of this form. It will help us if you make it clear which part of the form your information is about.
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W elsh English 7KURXJKR XWWK HIRU PZHDV NTX HV WLRQVD ERXW\RXDQ G\RXU SDU WQ HU% \SDUWQHUZH PHD Q DKXVEDQG ZLIHR U FLYLO SDUWQH URU VRPH RQH\ RXOLYH ZL WK DVLIWKH \ZHUH\RXUKXVEDQGZLIHRUFLYLOSDUWQHU $FLYLOSDUWQHULV someone who has entered into a formal agreement (known as a civil partnership) with a same-sex partner so they have the same legal status as a married couple.) Daytime phone number XS\RXUFODLPLIZHQHHGWRFRQWDFW\RX Email address $UH\RXJHWWLQJ,QFRPH6XSSRUWLQFRPHEDVHG-REVHHNHU¶V$OORZDQFH3HQVLRQ&UHGLW *XDUDQWHH&UHGLW or income-related Employment and Support No Allowance? Yes No Q Yes Q No Q Yes Q No Q Yes Q No Q Yes Q 3 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 4 Q %LUWKFHUWL¿FDWH Q Driving licence Q Passport (it must be current and valid) £ £ Q *DVZDWHURUHOHFWULFLW\ELOO WKDW\RXKDYHUHFHLYHGLQWKHODVWWKUHHPRQWKV Q Bank statements (that you have received in the last four weeks) D Yes Q 0DUULDJHFHUWL¿FDWH Q /HWWHURIFRQ¿UPDWLRQIURPDVROLFLWRUDVRFLDOZRUNHUDSUREDWLRQRI¿FHURUIURP+05HYHQXH &XVWRPV Q Medical card Q Divorce or annulment papers Yes Q UK residence permit Q +RPH2I¿FH6WDQGDUG$FNQRZOHGJHPHQW/HWWHU 6$/RU Q 3 JLYHQWR\RXZKHQ\RXOHDYHDMRE Q P60 (your yearly tax statement if you are working) Q Wage slips from your current employer No Yes Q A letter from the Department for Work and Pensions Q National Insurance card (RD3)No Yes Q $OHWWHUIURP+05HYHQXH &XVWRPV Q A SStatetate PPensionension oorr TWorkingax Cred Taxit le tCreditter letter Yes Q A bank statement (if you are self-employed and paying class 2 National Insurance contributions by direct debit) Which document are you using to FRQ¿UP\RXU1DWLRQDO,QVXUDQFHQXPEHU" No Which other document are you providing Yes WRFRQ¿UP\RXULGHQWLW\" What is your nationality? Yes What date did you last arrive in the UK? / / / / Are you seeking asylum in the UK? No Q Yes Q No Q Yes Q 4 No No / / / / A / / / / A Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 5 6HFWLRQ 7KHDQVZHUV\RXJLYHWRWKHIROORZLQJTXHVWLRQVZLOOPDNHVXUHWKDW\RXJHWWKHULJKWDPRXQWRIEHQH¿WLI\RX KDYHDGLVDELOLW\ Postcode: Postcode: No Have you claimed Carer’s Allowance but have been UHIXVHGEHFDXVH\RXJHWDQRWKHUEHQH¿W" 1RQ Yes Q No Q Yes Q / / / / ,Iµ<HV¶ZKHQGLG \RXF ODLP" A :KLFKEHQH¿WGR\RXJHWLQVWHDG" 5 / / / / A Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 6 6HFWLRQ$ERXW\RXUFKLOGUHQDQGIUHHVFKRROPHDOV 3OHDVHJLYHGHWDLOVDERXWDQ\FKLOGUHQZKROLYHZLWK\RXDQGZKR\RXRU\RXUSDUWQHUJHW&KLOG%HQH¿WIRU,I RWKHUFKLOGUHQOLYHZLWK\RXSHUPDQHQWO\DQG\RXRU\RXUSDUWQHUGRQRWJHW&KLOG%HQH¿WIRUWKHPWKH\VKRXOG EHLQFOXGHGLQVHFWLRQRQWKHQH[WSDJH +DYH\RXRU\RXUSDUWQHUDSSOLHGIRU RUDUHJHWWLQJ&KLOG%HQH¿W" 1RQ*RWRVHFWLRQ / / / / / / / / If you do not want to receive free school meals please tick here. Q / / / / / ,I\RXGRQRWZDQWWRUHFHLYHD'LVWLQFWLYH6FKRRO8QLIRUP*UDQW Q please tick here (comprehensive schools only). 3OHDVHUHDGWKHQRWHVRQSDJHDERXWIUHHVFKRROPHDOVDQG'LVWLQFWLYH6FKRRO8QLIRUP*UDQWV Do any of these children get Disability Living Allowance or No Q Yes Q Who? N Yes No Yes Yes Personal Independence Payment? Are any of these children registered blind? No Q Yes Q Who? 1 Yes No Yes Yes Have any of these children been registered blind in the last 28 weeks? No Q Yes Q Who? a Do you or your partner make payments for childcare? No Q*RWRVHFWLRQYes Q Please tell us about this below. :HQHHGWRVHH¿YHUHFHLSWVIRUFKLOGFDUHLI\RXSD\ZHHNO\RUWZRLI\RXSD\PRQWKO\DQG\RXUFRQWUDFW LI\RXKDYHRQH ,IWKHDPRXQW\RXSD\YDULHVGXULQJWHUPWLPHKROLGD\VRUEHFDXVHRI\RXUZRUNSDWWHUQV No Yes Yes Yes please give full details for a three-month period and send us receipts. What is the name and address of \RXUUHJLVWHUHGFKLOGPLQGHURUWKHQXUVHU\ playscheme or after-school club? Postcode: No Yes No Yes Yes What is their registration or reference number? This will be on your contract. What is the name of the child or children being cared for? No Yes No Yes Yes How much do you spend each week £ on childcare? Yes 'RHVWKHDPRXQW\RXSD\YDU\ IRUH[DPSOHGXULQJWHUPWLPHKROLGD\VRUEHFDXVHRI\RXUZRUNSDWWHUQV " No Q Yes Q 6 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 7 6HFWLRQ2WKHUSHRSOHOLYLQJLQ\RXUKRPH 2WKHUWKDQWKHSHRSOHPHQWLRQHGLQVHFWLRQVDQGGRHVDQ\RQHHOVHOLYHLQ\RXUKRPH" No Q*RWRVHFWLRQ 3HUVRQRQH 3HUVRQWZR 3HUVRQWKUHH First names Last name Date of birth / / / / / / / / / / / 5HODWLRQVKLSWR\RX VXFKDVVRQ GDXJKWHUIULHQGDQGVRRQ 'RWKH\JHW,QFRPH6XSSRUW3HQVLRQ&UHGLW *XDUDQWHH&UHGLW LQFRPHUHODWHG(PSOR\PHQW 6XSSRUW$OORZDQFHRU income-based UJobseeker’sniversal C rAllowance?edit? No Q Yes Q No Q Yes Q No Q Yes Q Do they normally work for more than 16 hours or more a week? No Q Yes Q No Q Yes Q No Q Yes Q No What are their earnings EHIRUH tax and National Insurance are taken off? £ £ £ No 'RWKH\JHWDQ\RWKHULQFRPHVXFKDV6WDWH5HWLUHPHQW3HQVLRQ:RUNLQJ7D[&UHGLW3HQVLRQ&UHGLWHPSOR\PHQW and Support Allowance or other pension? No Q Yes Q No Q Yes Q No Q Yes Q ,Iµ<HV¶ZKDWGRWKH\JHW" N How much are they receiving? £ £ £ Do they get interest on their savings? No Q Yes Q No Q Yes Q No Q Yes Q ,Iµ 'RWKH\KDYHDVHYHUHOHDUQLQJGLVDELOLW\ mental illness or a form of dementia? No Q Yes Q No Q Yes Q No Q Yes Q o Are any of the people you have mentioned above married to each other or living together as if they were married or living together as civil partners? No Q Yes Q Yes Tell us their names. is the partner of 7 No / / / / A Yes Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 8 3DUW%%RDUGHUVORGJHUVRUWHQDQWV 'R\RXVKDUH\RXUKRPHZLWKERDUGHUVORGJHUVRUWHQDQWV" 1RQ Yes Q ,Iµ 7KHLUIXOOQDPH 7KHLUGDWHRIELUWK +RZPXFKUHQWGR\RX +RZRIWHQ" N FKDUJHWKHP" / / £ / / £ Do you give them meals? No Q Yes Q Is a charge for heating included in the rent? No Q Yes Q 6HFWLRQ6WXGHQWV Are you or your partner a student? No Q*RWRVHFWLRQ Q Are you studying full-time / part-time? Full time Q Part time Q Full time Q Part time Q What course are you following Yes IXUWKHUHGXFDWLRQFRXUVHVXFKDV+1'%6F06F " When does the current academic year start? / / / / When does the current academic year end? / / / / How many years does the course cover? What is your current year of study? 1st Q 2nd Q 3rd Q WKQ 1st Q 2nd Q 3rd Q WKQ Do you receive a student grant? No Q Yes Q No Q Yes Q ,Iµ ,Iµ ,Iµ 8 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 9 6HFWLRQ3HQVLRQV Do you pay into a private pension scheme? No Q*RWRVHFWLRQ 6HFWLRQ :RUNLQJIRUDQHPSOR\HU What is the company’s address? Postcode: Postcode: Company phone number What is your payroll number (this will be on your payslip)? Yes How many hours do you normally work each week? +RZRIWHQDUH\RXSDLG HYHU\ZHHNHYHU\WZRZHHNV Yes every four weeks or every month)? / / / / When did you start this job? Yes +RZDUH\RXSDLG E\FKHTXHFDVKRULQWR\RXUEDQNDFFRXQW " ,I\RXUZDJHVDUHSDLGLQWRDQDFFRXQWUHPHPEHU to tell us about it in section 10. Yes How much are you paid? When will your next pay rise be? / / / / Yes 'R\RXZRUNUHJXODURYHUWLPHRUJHWUHJXODUERQXVHV Q Q Q Q tips or commission? No Yes No Yes ,Iµ 9 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 10 ,Iµ Do you have more than one job? No Q Yes Q No Q Yes Q Job title ,Iµ ,I\RXRU\RXUSDUWQHUKDYHPRUHWKDQWZRMREVSOHDVHJLYHXVGHWDLOVLQVHFWLRQ Cash 6HOIHPSOR\HG Direct bank transfer Q Q Are you or your partner self-employed? No *RWRVHFWLRQ What is your business called? Job title What is your business address? S Postcode: Postcode: When did your business start? / / / / How much do you earn each week? hours hours How many hours do you normally work each week? Do you have a business partner? No Q Yes Q No Q Yes Q Cash Do you have a government business allowance? No Q Yes Q No Q Yes Q Is this the only work you do? No Q Yes Q No Q Yes Q (If ‘No’ please tell us about this in section 12.) Direct bank transfer Tax code 10 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 11 (PSOR\HU¶VFRQ¿UPDWLRQRI\RXUHDUQLQJV 3OHDVH¿OOLQWKLVVHFWLRQDQGDVN\RXUHPSOR\HUWR¿OOLQWKHQH[WVHFWLRQWKHQVHQGLWWRWKHIROORZLQJ Yes DGGUHVV%ULGJHQG&RXQW\%RURXJK&RXQFLO32%R[%ULGJHQG&):%3KRQH Phone: 01656 643396 7REH¿OOHGLQE\WKHHPSOR\HH Name National Insurance number Address Date of birth / / No Yes Postcode: Job title Signature Payroll number 7REH¿OOHGLQE\WKHHPSOR\HU 3OHDVHKHOS\RXUHPSOR\HHE\¿OOLQJLQWKHLQIRUPDWLRQZHDVNIRUEHORZDQGRYHUWKHSDJH(DUQLQJV EHIRUH WD[DQG1DWLRQDO,QVXUDQFHKDYHEHHQWDNHQRXW VKRXOGLQFOXGHDQ\ERQXVHVRYHUWLPH6WDWXWRU\6LFN3D\ 6WDWXWRU\0DWHUQLW\3D\6WDWXWRU\3DWHUQLW\3D\FRPPLVVLRQDQGVRRQ3OHDVHJLYHWKLVIRUPEDFNWR\RXU employee or send it to the address above. +RZRIWHQGRHV\RXUHPSOR\HHJHWSDLG" +RZGR\RXSD\\RXUHPSOR\HH" Every week Q 3OHDVHJLYHGHWDLOVRIODVW¿YHSD\SHULRGV Every two weeks Q Please give details of last three pay periods. Cash Q Every four weeks Q Please give details of last two pay periods. Cheque Q Every month Q Please give details of last two pay periods. Direct bank transfer Q Normal hours worked each week hours Tax code 3OHDVHWXUQRYHU (PSOR\HU¶VFRQ¿UPDWLRQRI\RXUHDUQLQJV 3OHDVH¿OOLQWKLVVHFWLRQDQGDVN\RXUHPSOR\HUWR¿OOLQWKHQH[WVHFWLRQWKHQVHQGLWWRWKHIROORZLQJ DGGUHVV%ULGJHQG&RXQW\%RURXJK&RXQFLO32%R[%ULGJHQG&):%3KRQH Phone: 01656 643396 7REH¿OOHGLQE\WKHHPSOR\HH Name National Insurance number Address Date of birth / / Postcode: Job title Signature Payroll number 7REH¿OOHGLQE\WKHHPSOR\HU 3OHDVHKHOS\RXUHPSOR\HHE\¿OOLQJLQWKHLQIRUPDWLRQZHDVNIRUEHORZDQGRYHUWKHSDJH(DUQLQJV EHIRUH WD[DQG1DWLRQDO,QVXUDQFHKDYHEHHQWDNHQRXW VKRXOGLQFOXGHDQ\ERQXVHVRYHUWLPH6WDWXWRU\6LFN3D\ 6WDWXWRU\0DWHUQLW\3D\6WDWXWRU\3DWHUQLW\3D\FRPPLVVLRQDQGVRRQ3OHDVHJLYHWKLVIRUPEDFNWR\RXU employee or send it to the address above. +RZRIWHQGRHV\RXUHPSOR\HHJHWSDLG" +RZGR\RXSD\\RXUHPSOR\HH" Every week Q 3OHDVHJLYHGHWDLOVRIODVW¿YHSD\SHULRGV Yes Every two weeks Q Please give details of last three pay periods. Cash Q Yes Every four weeks Q Please give details of last two pay periods. Cheque Q Yes Every month Q Please give details of last two pay periods. Direct bank transfer Q Normal hours worked each week hours Tax code 3OHDVHWXUQRYHU 11 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 12 3D\SHULRG 3D\EHIRUH ,QFRPHWD[ 1DWLRQDO 7D[&UHGLW 3HQVLRQ 3D\DIWHU 1XPEHU HQGLQJ WD[DQG ,QVXUDQFH SD\PHQWV WD[DQG RIKRXUV 1DWLRQDO 1, 1DWLRQDO ZRUNHGLQ ,QVXUDQFH ,QVXUDQFH WKLVSHULRG 1. £ £ £ £ £ £ 2. £ £ £ £ £ £ 3. £ £ £ £ £ £ ££££££ 5. £ £ £ £ £ £ Pay (before tax and National Insurance) so far for the current year from / / to / / Pay EHIRUHWD[DQG Tax NI Pension Net pay 1DWLRQDO,QVXUDQFH Are these normal earnings? No Q Yes Q If ‘No’ please explain here: Employer’s name and address Postcode: Phone number Employer’s authorisation stamp The information I have given is true and complete. Your signature Position in your Date / / company r Yes 3D\SHULRG 3D\EHIRUH ,QFRPHWD[ 1DWLRQDO 7D[&UHGLW 3HQVLRQ 3D\DIWHU 1XPEHU HQGLQJ WD[DQG ,QVXUDQFH SD\PHQWV WD[DQG RIKRXUV 1DWLRQDO 1, 1DWLRQDO ZRUNHGLQ ,QVXUDQFH ,QVXUDQFH WKLVSHULRG 1. £ £ £ £ £ £ 2. £ £ £ £ £ £ 3. £ £ £ £ £ £ ££££££ 5. £ £ £ £ £ £ Pay (before tax and National Insurance) so far for the current year from / / to / / Pay EHIRUHWD[DQG Tax NI Pension Net pay 1DWLRQDO,QVXUDQFH Are these normal earnings? No Q Yes Q If ‘No’ please explain here Employer’s name and address Postcode: Phone number Employer’s authorisation stamp The information I have given is true and complete. Your signature Position in your Date / / company 12 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 13 6HFWLRQ%HQH¿WLQFRPH 'R\RXRU\RXUSDUWQHUUHFHLYHDQ\RIWKHEHQH¿WVOLVWHGEHORZRUDUHZDLWLQJWRKHDUDERXWDEHQH¿WWKDW\RXKDYH claimed for? No Q*RWRVHFWLRQ D +RZRIWHQGR\RX Tax NI Pension Net pay %HQH¿WVUHFHLYHG ,QFDSDFLW\%HQH¿W Child Tax Credit £ £ Working Tax Credit £ £ Pension Credit (Savings Credits) £ £ State Retirement Pension £ £ Date / / Universal Credit £ £ c Have you or your partner chosen to delay receiving your State Retirement Pension? No Q Yes Q We will write to you about this. 3OHDVHWHOOXVKHUHDERXWDOOWKHGLIIHUHQWEHQH¿WVDOORZDQFHVSHQVLRQVDQGWD[FUHGLWVWKDW\RXRU\RXU partner get or have applied for. This includes things like: Q Severe Disablement Allowance Q Carer’s Allowance Q Maternity Allowance Q ,QGXVWULDOLQMXULHV'LVDEOHPHQW%HQH¿W Q Fostering Allowance Q Widow’s Pension Q Bereavement Allowance Q Widowed Mother’s Allowance Q War Widow’s Pension and War Disablement Pension Q Widowed Parent’s Allowance 7KHVHDUHRQO\H[DPSOHV,WLVQRWDOLVWRIDOOWKHW\SHVRIEHQH¿WLQFRPH\RXFDQJHW +RZRIWHQGR\RX 1DPHRIEHQH¿W P ££ Tax NI Pension Net pay ££ ££ Yes ££ ££ ££ %HQH¿WVFODLPHG +DYH\RXFODLPHGDEHQH¿WWKDW\RXDUHZDLWLQJWRKHDUDERXW"1RQ Yes Q No Q Yes Q ,Iµ 13 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 14 6HFWLRQ D2WKHULQFRPH\RXUHFHLYH Do you or your partner receive any of the types of income listed below? No Q*RWR %DWWKHERWWRPRIWKHSDJH How much private or other pension do you get? ££ When was your last increase? / / / / Who pays you this pension? Are you over 60 and have you chosen to receive your works pension at a future date? No Q Yes Q No Q Yes Q ,I\RXUHFHLYHDQ\RIWKHIROORZLQJLQFRPHVSOHDVHWHOOXVKRZPXFKLQWKHVSDFHVSURYLGHG Q Pension Protection Fund Q Home income plan Q Mortgage-protection policy Q Councillor allowances Q Income from property or land you own Q Income from a trust fund Q Maintenance for yourself Q Loan-protection policy Q Charitable or voluntary payments suchQPayments instead of coal DVSD\PHQWVIURPIULHQGVIDPLO\RUFKDULW\ Q Any other income Please say where this income comes from and how often you get it. +RZRIWHQGR\RX 1DPHRILQFRPH ££ ££ No Yes Yes ££ ££ Yes Yes ££ Yes Yes ££ 6HFWLRQ %SD\PHQWV\RXPDNH Do you or your partner pay towards a son or daughter going to university or college? No Q*RWRVHFWLRQ 14 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 15 6HFWLRQ$FFRXQWVVDYLQJVDQGLQYHVWPHQWV 3OHDVHWHOOXVEHORZDERXWDQ\DFFRXQWVFDVKVDYLQJVDQGLQYHVWPHQWV\RXRU\RXUSDUWQHUKDYH7KLV N LQFOXGHVDOOEDQNEXLOGLQJVRFLHW\RUSRVWRI¿FHDFFRXQWVWKDW\RXKDYHHYHQLIWKHDFFRXQWVDUHRYHUGUDZQ :HDOVRQHHGWRNQRZDERXWDQ\VDYLQJV\RXKDYHLQYHVWHGLQERQGVVDYLQJVFHUWL¿FDWHVVWRFNVVKDUHVXQLW trusts and any property or land that you or your partner own. Please tick ‘No’ if something does not apply to \RXRU\RXUSDUWQHU:HQHHGSURRIRIDOO\RXUDFFRXQWVVDYLQJVDQGLQYHVWPHQWV:HDFFHSWWKHIROORZLQJ Q %DQNEXLOGLQJVRFLHW\DQGSRVWRI¿FHVWDWHPHQWVRUSDVVERRNV7KHVHPXVWFRYHUDWOHDVWWKHODVWWZR months. We cannot accept balance slips showing the current amount. Q $OHWWHUIURP\RXUEDQNRUEXLOGLQJVRFLHW\7KLVVKRXOGVKRZWKHW\SHRIDFFRXQWKHOGWKHDFFRXQWQXPEHU the current balance and details of any transactions you have made in the last two months. o )RULQYHVWPHQWVRURWKHUVDYLQJV VXFKDVXQLWWUXVWVDQGVDYLQJVFHUWL¿FDWHV ZHQHHGWRVHHGRFXPHQWVWKDW prove that you own them. $OOGRFXPHQWV\RXVHQGXVPXVWEHRULJLQDOV:HFDQQRWDFFHSWSKRWRFRSLHV 3DUWD Do you or your partner have any accounts? No Q Yes Q 7KHVHLQFOXGHFXUUHQWGHSRVLWDQGVDYLQJVDFFRXQWVZLWKDEDQNEXLOGLQJVRFLHW\SRVWRI¿FHDFFRXQWVDQG DQ\RWKHUDFFRXQWVZLWKD¿QDQFLDORUJDQLVDWLRQ,Iµ 6RUWFRGHDQGDFFRXQWQXPEHU $PRXQW :KRVHDFFRXQWLVLW" £ £ £ r Yes £ £ £ £ £ Please say where this income comes from £ and how often you get it. £ £ Cash savings No Q Yes Q No Q Yes Q Premium Bonds No Q Yes Q No Q Yes Q ,6$7(66$ 1RQ Yes Q No Q Yes Q PEP or TOISA No 15 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 16 'R\RXRU\RXUSDUWQHUKDYHDQ\VWRFNVVKDUHVERQGVXQLWWUXVWVRU1DWLRQDO6DYLQJV&HUWL¿FDWHV" No Q*RWRSDUW%EHORZ 6WRFNVVKDUHVERQGVDQGXQLWWUXVWV 1DWLRQDO6DYLQJV&HUWL¿FDWHV 1DPHRIVWRFNV 1XPEHU 1DPHRIFRPSDQ\ VKDUHVERQGV ,VVXHQXPEHU RIXQLWV RUWUXVWXQLWV F 3DUW% Do you qualify for any money from a trust? No Q Yes Q No Q Yes Q Do you have any business interest which you have No Q Yes Q No Q Yes Q not told us about on this form? / ,I\RXKDYHDQVZHUHGµ Which bank or company is this money saved or invested in? No Do you or your partner own any other property or land Six months Other (please tell us) other than the one you are claiming for? No Q *RWRVHFWLRQ This includes properties in this country and abroad. Yes Q Please answer these questions. D What is the full address of the property or land? Postcode: Does anyone else own this property or land with you or your partner? No Q Yes Q*LYHXVWKHLUGHWDLOVLQVHFWLRQ E / Is the property or land up for sale? No Q Yes Q W ,Iµ Do people live in the property? No Q Yes Q ,IWKHSURSHUW\LVOLYHGLQSOHDVHJLYHSHRSOH¶VQDPHV ( No DQGWKHLUUHODWLRQVKLSWR\RX VXFKDVSDUHQWH[SDUWQHU tenant and so on). Postcode: s a $OOGRFXPHQWV\RXVHQGXVPXVWEHRULJLQDOV:HFDQQRWDFFHSWSKRWRFRSLHV No 16 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 17 6HFWLRQ$ERXW\RXUUHQW We need to see original proof of the rent you have to pay. We accept your tenancy agreement or your rent ERRNDVSURRIOI\RXGRQRWKDYHHLWKHURIWKHVHSOHDVHDVN\RXUODQGORUGRUDJHQWWR¿OOLQWKHHQFORVHGSURRI of rent form. ,I\RXUUHQWLVUHJLVWHUHGZLWK7KH5HQW6HUYLFHZHDOVRQHHGWRVHH\RXUFXUUHQWUHJLVWUDWLRQGRFXPHQW First names Last name Company name Yes Address Postcode: Postcode: Yes Phone number No Yes When did you start renting your home? / / When did you move into this address? / / Yes +DV\RXUUHQWEHHQUHJLVWHUHGDVDIDLUUHQWE\WKH9DOXDWLRQ2I¿FH$JHQF\ 1RQ Yes Q (who used to be The Rent Service)? Do you have a shorthold tenancy? No Q Yes Q How long is your tenancy for? Six months Q 12 months Q Other (please tell us) o Does anyone else share the rent with you and your partner? No Q Yes Q ,Iµ How much notice do you have to give to end your tenancy? £ How much is your rent? How often is your rent due? w Yes Every week Q Every two weeks Q Every four weeks Q Every month Q Other (please tell us) / / Yes What was the date of your last rent increase? ,I\RXDUHEHKLQGZLWK\RXUUHQWSOHDVHWHOOXVKRZPDQ\ZHHNV\RXDUHEHKLQG weeks Is any part of your home used for business purposes? No Q Yes Q Is your home part of a shared-ownership scheme (known as New Build Home Buy)? No Q Yes Q Is your home a part of a co-ownership scheme? (A co-ownership scheme is one where the tenant is a member of the association No Q Yes Q that they rent a house from and when this ends will be entitled to a payment related to the value of the house.) Has anyone who used to live with you died in the last 12 months? No Q Yes Q 17 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 18 7KHSURSHUW\\RXOLYHLQ Is your home: a house? Q DÀDW" Q a room or rooms in a house? Q a bungalow? Q a bedsit? Q a maisonette? Q lf your house isn’t described by any RIWKHRSWLRQVDERYHSOHDVHVD\ZKDW type of home you live in here. Is your property: terraced? Q semi-detached? Q detached? Q +RZPDQ\ÀRRUVGRHVWKHZKROHEXLOGLQJKDYH" Is your property let as: fully furnished? Q partly furnished? Q not furnished? Q How much of the furniture is provided by your landlord? None Q Some Q Most Q All Q Is your landlord responsible for decorating the inside of your home? No Q Yes Q Does your home have central heating? No Q Yes Q Do you have a garage? No Q Yes Q No Yes Does your home have a parking area? No Q Yes Q No Yes ,I\RXUHQWDURRPÀDWRUEHGVLW\RXPXVW¿OOLQWKLVVHFWLRQRU\RXUFODLPFRXOGEHGHOD\HG. ,I\RXGRQ¶WVNLSWKLVTXHVWLRQ No Yes :KLFKÀRRULV\RXUKRPHRQ" No Yes No Yes 6HFRQGÀRRUQ No Yes )LUVWÀRRUQ No Yes *URXQGÀRRUQ Other (please tell us) Yes Basement Q Yes No Yes ,I\RXDUHIDFLQJWKHIURQWRIWKHEXLOGLQJLV\RXUKRPH No Yes at the front? Q in the centre? Q at the back? Q Yes What is your room or bedsit number? No Yes +RZPDQ\ÀDWVRUEHGVLWVDUHWKHUHLQ\RXUEXLOGLQJ" Are you or your partner a Foster Carer? (We will write to you about this.) No Q Yes Q No Yes Do you or your partner need a bedroom for an overnight carer who does not live permanently at your address but stays regularly to provide care services? No Yes (We will write to you about this.) No Q Yes Q i No Yes No Yes No Yes No Yes 18 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 19 Please tell us the number of rooms in the property. %HGVLWV RQHURRPHG 2WKHU /LYLQJ KRXVLQJ 6HSDUDWH URRPV %HGURRPV ZKLFK .LWFKHQV %DWKURRPV URRPV WRLOHWV VXFKDV FRPELQHV DVWXG\RU VOHHSLQJDQG XWLOLW\DUHD OLYLQJDUHD How many of these rooms are there in your property? How many are only used by you and your family? How many of these rooms do you share with other people (including other tenants or your landlord)? 6HUYLFHV 3OHDVHWHOOXVLIDQ\RIWKHIROORZLQJVHUYLFHVDUHLQFOXGHGLQ\RXUUHQWOI\RXWLFNµ Laundry equipment (such as a washing machine) No Q Yes Q £ Laundry or bed linen that is washed for you No Q Yes Q £ *DUDJH 1RQ Yes Q £ Emergency-alarm system No Q Yes Q £ Counselling and support (which is help given :HPD\ZULWHWR WRFODLPEHQH¿WVDQGEXGJHWDQG \RXWRJHWPRUH ( No debt counselling) No Q Yes Q £ LQIRUPDWLRQDERXW WKHVH Nursing and personal care (which is help c JLYHQWRKHOS\RXWDNH\RXUPHGLFLQH b bathe or dress) No Q Yes Q £ No Other service (please say what it is in the box provided) No Q Yes Q £ Breakfast No Q Yes Q £ Lunch No Q Yes Q £ Evening meal No Q Yes Q £ 19 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 20 Are you renting your home from a housing association? No Q Please answer the following questions. Yes Q*RWRWKHQH[WSDJH $UH\RXRU\RXUSDUWQHUUHODWHGWR\RXUODQGORUGRU\RXUODQGORUG¶VSDUWQHU or to your agent or your agent’s partner (if you have an agent)? No Q Yes Q 3OHDVHVD\KRZ\RXDUHUHODWHG VXFKDVH[SDUWQHUSDUHQW EURWKHUEURWKHULQODZVWHSEURWKHUDQGVRRQ Are any of your children or your partner’s children related to your landlord or landlord’s partner or to your agent or agent’s partner (it you have an agent)? No Q Yes Q your landlord (if you don’t quality for LHA)? Who? What is their relationship IRUH[DPSOHVRQEURWKHUIDWKHUPRWKHUGDXJKWHU " Has your landlord ever lived in your property? No Q Yes Q $UH\RXRU\RXUSDUWQHUDGLUHFWRURIRUHPSOR\HGE\WKHFRPSDQ\ who are your landlord? No Q Yes Q ,V\RXUH[SDUWQHURU\RXUSDUWQHU¶VH[SDUWQHUDGLUHFWRURIRU HPSOR\HGE\WKHFRPSDQ\ZKRLV\RXUODQGORUG" 1RQ Yes Q ,VDQ\RI\RXUKRXVHKROGDGLUHFWRURIRUHPSOR\HGE\ the company who is your landlord? No Q Yes Q Do you pay rent to a trust where either you or your partner are trustees WUXVWHHVORRNDIWHUSURSHUW\IRUWKHEHQH¿WRIVRPHRQHHOVH " 1RQ Yes Q Do you pay rent to a trust where either your ex-partner or your partner’s ex-partner is a trustee? No Q Yes Q Do you pay rent to a trust where any member of your household (including children) is a trustee? No Q Yes Q Have you or your partner ever owned all or owned part of the property you are renting? No Q Yes Q Do you have to rent your home as a condition of your employment? No Q Yes Q Are you living in a property that is maintained by a religious group (such as a church)? No Q Yes Q OI\RXKDYHDQVZHUHGµ l N Yes ,I\RXDUHXQGHU\HDUVRIDJHSOHDVHDQVZHUWKHVHTXHVWLRQV Have you ever been in care (looked after by a local authority)? No Q Yes Q Have you ever been given housing by Social Services? No Q Yes Q ,I\RXKDYHDQVZHUHGµ 20 l N Yes Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 21 +HRZZHZLOOSD\\RXow we will pa y you Yes 7HQDQWVDSS O\LQJIRU/RF DO+RXVLQJ$OOR ZDQFH /+$ ZHZLOOSD\+RXVLQJ%HQH¿WGLUHFWWR\RXRU\RXU SDUWQHUOI\R XIHHOWKDWWKLVP D \FD XVHD SUREOHPSOHDVHSKRQHXVoRnQ 01656 643396. +RXVLQJDVVRFLDWLRQDQGWHQDQWVWKDWGRQRWTXDOLI\IRU/+$ ZHFDQSD\+RXVLQJ%HQH¿WWR\RX\RXU partner or your landlord‘s agent. ,I\RXJHW+RXVLQJ% HQ H¿WRU/RFDO+RX VLQ J$OORZ DQFHDQG \R XD UHK DYLQJ P RQH \SUREOHPVRU\RXKDYH SUREOH PV WKDWD IIHFW\RXSD \LQJ\ R XUUHQWWR\ RXUODQGORU GW KHQZHP D\ EHD EOHWRK HOS 3OHD V HFRQWDFWXVRQ Yes thel number above to tell us your problem N and we Yes will try to help you or put you in contact with an organisation No who can help you. o Do you want us to pay: you? Q your landlord (if you don’t quality for LHA)? Q your partner? Q your landlord’s agent (if you don’t qualify for LHA)? Q What is their relationship :WHe FcDaQn SpDa\y +HRoXu VsLiQnJg %BHeQn He¿fiWt VsWtUrDaLiJgKhWt LiQnWtRo \yRoXuUr RoUr \yRoXuUr SpDaUrWtQnHeUr’¶Vs EbDaQnNk, EbXuLiOlGdLiQnJg VsRoFcLiHeWt\y RoUr RoWtKhHeUr DaFcFcRoXuQnWt (He[xFcHeSpWt 3PRoVsWt 2OIf¿fiFcHe FcDaUrGd DaFcFcRoXuQnWtVs ). ,IIf \yRoXu ZwDaQn Wt XuVs WtRo SpDa\y \yRoXu LiQn WtKhLiVs ZwDa\y WtKhHeQn SpOlHeDaVsHe ¿fiOlOl LiQn WtKhHe VsHeFcWtLiRoQn EbHeOlRoZw. :WHe SpDa\y No HYHU\WZRZHHNVRUPRQWKO\IRUWKHSUHYLRXVWZRZHHNVRUPRQWK,I\RXGRQRWJLYHXV\RXUEDQNGHWDLOVZHevery four weeks or monthly for the previous four weeks or mo nth. If you do not give us your bank details, we ZLOOSD\\RXE\FKHTXH,I\RXKDYHDVNHGXVWRPDNHWKHSD\PHQWRXWWR\RX\RXZLOOQHHGDEDQNDFFRXQWLQwill pay you by cheque. If you have asked us to m ake the payment out to you, you will need a bank account in youryour namenam e soso youyou cancan cashcas h thethe cheque.che que. No ,I\RXGRQRWKDYHDEDQNDFFRXQWDQGZRXOGOLNHWRRSHQRQHZHFDQJLYH\RXDGYLFHRQKRZWRRSHQ RQH3OHDVHSKRQHXVRQ on 01656 643396. Name the account is in No Name of bank or building society Branch address No p No Postcode: Sort Code -- ( No Accountl number N Yes p No Building society roll number 6KDULQJ,QIRUPDWLRQSharing Information ( No Sharing information with your landlord could help us deal with your claim more quickly. We may need to ask WKHPIRUGHWDLOVDERXW\RXUFODLPVXFKDVZKHQ\RXUWHQDQF\EHJDQRUWKH\PD\DVNXVDERXWWKHSURJUHVVRI \RXUFODLP: HZLOOQ RWJLYH\RXUODQGORUGDQ\LQIRUPDWLRQUHJDUGLQJ\RXUSHUVRQDORU¿QDQFLDOFLUFXPVWDQFHV )RUH[DPSOHZKDWW\SHRILQFRPH\RXJHWRU\RXUGDWHRIELUWKRU1DWLRQDO,QVXUDQFHQXPEHU No Can we share information about \RXUFODLP (including the progress of your claim) with your landlordl or agent? No NQ Yes Yes Q ,Iµ / / / / A 21 No / / / / A Yes Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 22 %DFNGDWLQJEHQH¿WFODLPV :HQRUPDOO\SD\EHQH¿WIURPWKH0RQGD\DIWHUZHUHFHLYH\RXUFODLP6RPHWLPHVZHFDQSD\IURPDQHDUOLHU GDWHLI\RXK DYHJRRGUHDVRQVZK\\RXKDYHQRWFODLPHGHDUOLHU,I\RXZDQWXVWRFRQVLGHUSD\LQJ\RXUEHQH¿W IURPDQHDUOLHUGDWHSOHDVHJLYHDVPXFKGHWDLODV\RXFDQLQWKHVSDFHEHORZ Tell us the date you want to claim from. / / Please tell us why you did not claim earlier. / / P Section 12 &KHFNOLVW 3OHDVHFKHFNWKDW\RXKDYHDQVZHUHGDOOWKHTXHVWLRQVWKDWDSSO\WR\RX¿OOLQVHFWLRQDQGUHPHPEHU WRVLJQWKHIRUPLQVHFWLRQ,I\RXGRQRWKDYHWKHSURRIZHQHHGDWWKHPRPHQW VHQGWKHIRUPEDFNWR XVDQ\ZD\ : HZ LOOW KHQZU LWHWR\ RX WRF RQ ¿UPW KHG DWH ZHUHFHL YHG\ RXU FODLPDQGZHZLOODVN\RXIRUWKH ethnic group information and proof that we need. The letter we send you will include your claim form. You should send this EDFNWRXVZLWKDOOWKHGHWDLOVZHQHHG:HZLOOQRWEHDEOHWRSD\\RXEHQH¿WXQWLOZHKDYHDOOWKHSURRIZH need. Please tick the boxes below to tell us what you are sending with this form. Yes +DYH\RXJLYHQXV Yes proof of your identity and National Insurance number? Yes Q Yes Q Yes proof of your rent? Yes Q Yes Q Yes proof of all your income? Yes Q Yes Q proof of all your accounts and savings? Yes Q Yes Q Y proof of income for anyone else living in your home (if this applies)? Yes Q Yes Q DFHUWL¿FDWHRIHDUQLQJV" Yes Q Yes Q 5HPHP EHU LI\ RXGR QR WS URY LGHDO OWKHLQIR UPDW LRQ ZHK DYHDV NHG IRUR QWKLVIRUPZHPLJKWQRW EHDEOHWRSD\\RXDQ\EHQH¿W Please use this space to tell us about anything else you think might help your claim. Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 23 6HFWLRQ(TXDORSSRUWXQLWLHV :H QHHG WRFK HFNWK HHWKQLFJ URX SRIHYHU\RQHZKRDSSOLHVIRUEHQH¿WWRPDNHVXUHWKDWZHDUHPHHWLQJ \RXUQHHGV,WZRXOGEHKHOSIXOLI\RXFRXOG¿OOLQWKHIROORZLQJIRUPEXW\RXGRQ¶WKDYHWR / / :KDWLV\RXUHWKQLFJURXS" (Please tick the box that applies to you.) P / / $ White % Asian or Asian British & Mixed P Q WBritishelsh Q Indian Q White and Asian Q EEnglishnglish Q Pakistani Q White and black African Q SIrishcottish Q Bangladeshi Q White and Caribbean Q IWelshrish Q Any other Asian background Q Any other mixed background Q BScottishritish ' Black or black British ( Chinese or other Asian ) Other ethnic group ethnic group Q Caribbean Q Other (Please tell us) Q Chinese Q African Yes Q Japanese Q Any other black background Yes Q Any other Asian ethnic background Yes Yes Yes 8VHIXOFRQWDFWV Yes %ULGJHQG&LWL]HQV$GYLFH%XUHDX A$JH&RQFHUQge Cymru Afan Nedd Yes *URXQG)ORRU R32%R[iverside Walk 26 Dunraven Place Bridgend Yes Port Talbo t Yes Town Centre &) %< SA13 1PH Bridgend P3KRQH hone: 01639 892211 Yes CF31 1JD Website: www.ageconcern.org.uk Website: www.agecymru.org.uk/afannedd Y 3KRQH Website: www.citizensadvice.org.uk 3HQVLRQ6HUYLFH 32%R[ Y 0DHVWHJ &LWL]HQV$GYLFH%XUHDX Swansea3HQVLRQ6HUYLFH &RXQFLO2I¿FHV SA632%R[ 8WD Talbot Street 3KRQH Swansea SA6 8WD Maesteg Website: www.thepensionservice.gov.uk &) %< 3KRQH 3KRQH %ULGJHQG&UHGLW8QLRQWebsite: www.thepensionservice.gov.uk Website: www.citizensadvice.org.uk Lifelong Learning Centre 0HU¿HOG&ORVH%ULGJHQG&UHGLW8QLRQ Lifelong Learning Centre 6KHOWHU&\PUX Sarn 25 Walter Road &) 6:0HU¿HOG&ORVH Swansea 3KRQH Sarn SA1 5NN Website&) 6: www.abcul.org 3KRQH 3KRQH Website www.abcul.org Website: www.sheltercymru.org.uk 23 Housing Benefit Claim 24pp English Final:Layout 1 01/11/2016 13:03 Page 24 6HFWLRQ'HFODUDWLRQ ,I\RXDUH¿OOLQJLQWKLVIRUPIRUVRPHRQHHOVH 3OHDVHWHOOXVZK\\RXDUH¿OOLQJLQWKLVIRUPIRUVRPHRQHHOVH OFRQ¿UPWKDWOKDYHUHDGHDFKTXHVWLRQWRWKHSHUVRQFODLPLQJDQGOKDYHDFFXUDWHO\ZULWWHQWKHDQVZHUV they gave me. 1DPHRIWKHSHUVRQZKR¿OOHGLQWKHIRUP Signature of the person Relationship to the person claiming VXFKDVPRWKHUVRQRUFDUHZRUNHU 3OHDVHUHDGWKLVGHFODUDWLRQFDUHIXOO\EHIRUH\RXVLJQDQGGDWHLW Q OXQGHUVWDQGWKDWLI,JLYHLQIRUPDWLRQWKDWLVQRWFRUUHFWRUFRPSOHWH\RXPD\WDNHOHJDODFWLRQDJDLQVWPH Q OXQGHUVWDQGWKDW\RXZLOOXVHWKHLQIRUPDWLRQOKDYHJLYHQWRSURFHVVP\FODLPIRU+RXVLQJ%HQH¿W/RFDO +RXVLQJ$OORZDQFH&RXQFLO7D[5HGXFWLRQIUHHVFKRROPHDOVDQGD'LVWLQFWLYH6FKRRO8QLIRUP*UDQW Q You can check some of the information with other departments within Bridgend County Borough Council and with other councils. Q Your signature Date / / Your partner’s signature Date / / 5HPHPEHULI\RXPDNHDIDOVHVWDWHPHQWRUZLWKKROGLQIRUPDWLRQ\RXPD\EHSURVHFXWHG +RZZHFROOHFWDQGXVHLQIRUPDWLRQ :HZLOOXVHWKHLQIRUPDWLRQZHFROOHFWERWKRQWKLVIRUPDQGIURPVXSSRUWLQJHYLGHQFH\RXJLYHXVWRSURFHVV\RXUFODLP IRU+RXVLQJ%HQH¿W/RFDO+RXVLQJ$OORZDQFH&RXQFLO7D[5HGXFWLRQIUHHVFKRROPHDOVDQGD'LVWLQFWLYH6FKRRO8QLIRUP *UDQW2QFHZHFROOHFW\RXULQIRUPDWLRQZHPD\VKDUHLWZLWKRWKHUFRXQFLOGHSDUWPHQWVWRKHOSSURYLGHDFRPSOHWH service to you. We may check information you (or anyone else) have provided with other information we hold. :HPD\DOVRJHWLQIRUPDWLRQIURPRWKHURUJDQLVDWLRQVRUJLYHLQIRUPDWLRQWRWKHP Q WRFKHFNWKDWWKHLQIRUPDWLRQ\RXKDYHJLYHQLVDFFXUDWH Q WRSUHYHQWRUGHWHFWFULPH Q WRSURWHFWSXEOLFIXQGVLQRWKHUZD\V DQG Q for reasons allowed or required by law. :HZLOOXVH\RXULQIRUPDWLRQLQOLQHZLWKWKH'DWD3URWHFWLRQ$FW :H %ULGJHQG&RXQW\%RURXJK&RXQFLO DUHWKH GDWDFRQWUROOHUIRUWKHSXUSRVHVRIWKH'DWD3URWHFWLRQ$FW 24