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Important Notes Page 1 Part 1 – About You and Your Partner

Please fill in this form, either if You Your Partner you receive Universal Credit and Title (Mr, Mrs, Ms etc.) want to apply for Council Tax Support as well, or if you just First Names want to claim Council Tax Support only. Surname We use partner to mean Date of Birth / / / / • a person you are married to or a person you live with as if you Telephone Number are married to them, or Number • a civil partner or a person you live with as if you are civil Email address partners You need to ensure you give the correct information so we can ensure we are paying the correct amount of benefit. Part 2 – About Your Circumstances If you do not have room on the Please answer yes or no to the following: form to give us the answers to Do you or your partner receive Universal Credit? Yes No the questions on this page then We need to see your latest award breakdown from your online payment schedule. please use a separate piece of paper. Are you or your partner a full or part time student? Yes No We need your latest Grant & Loan Breakdown & your Student Certificate. Full time students are exempt from Council Tax. Do you or your partner work for an employer? Yes No We will need to see your latest wage slips, and know how many hours per week you work. Are you or your partner Self Employed? Yes No You will need to provide your latest trading accounts, or complete a Self Employed form at the forum. Do you or your partner receive any other DWP benefits? Yes No This can be Jobseekers Allowance, Employment and Support Allowance etc. Do you wish to claim Second Adult Rebate? Yes No This is where your claim is based wholly on the income of a Non-Dependant in your property. Do you wish to backdate your claim? Yes No Regulations allow us to backdate up to one month from the date this form was returned. Please turn to page 7 for more information on how to claim. Are you expecting a baby? Yes No If you answered yes, please give your expected due date. Part 3 – Children who live with you Important Notes Page 2

Do you have any children or adults also living with you? You need to tell us about anyone else who lives with you, including Yes dependent children and any other No adults (non-dependants). Name Relationship to you Date of birth ? Who Receives? A dependent child is someone: / / ● Aged under 16 years old; or ● Aged 16 or over, but under / / 20 and child benefit is still / / being paid for them. If you receive Child Benefit for / / any children, please answer yes or no opposite, and advise who receives Child Benefit for them.

Part 3 continued – Adults who live with you Non-dependants are usually grown up sons or daughters, or other Name Relationship to you Date of birth NI Number Move In Date relatives and friends who live in your home and do not pay you / / rent. They may give you some / / money to pay for their keep (board) but this money is not / / generally counted as your income. / / If anyone has moved in or out of your household, please tell us the date of the change. If any of the people listed above are children for whom you pay childminding costs to a registered childminder, nursery or after-school club, please give details below. Please give the name and You should also tell us about any registration number of the minder, the weekly charge, and the name of the child being cared for. We non-dependants who work away will also need to know if you pay for Child Care during term time only, or over the full year. from home but use your home as a base.

You need to provide proof of any Child Minding Costs, for example, to a Registered Child Minder, Nursery or After School Club. Important Notes Page 3 Part 4 – Benefits, Pensions, Credits or Allowances

Please provide proof of all benefits, Do you, your partner, or other adults in your property receive any DWP benefits? pensions, credits and allowances that you Yes If you receive Universal Credit, we need to see your latest award from your online payment schedule (all pages) and your partner receive. Examples of benefits you may receive are listed No below: You Attendance Allowance Type Amount How often Bereavement Benefits Carer’s Allowance £ Child Benefit/ £ Disability Living Allowance Care Disability Living Allowance Mobility £ Employment & Support Allowance £ Guardian’s Allowance Incapacity Benefit £ Your Partner Industrial Injuries Disablement Benefit Jobseeker’s Allowance Contribution Based Type Amount How often Jobseeker’s Allowance Income Based £ Maternity Allowance Mobility Allowance or Supplement £ Pension Credits £ Personal Independence Payments Private Pension £ State Pension £ Universal Credit Working Tax Credits Other Adults Name of Adult Type Amount How often £ £ £ £

Does anyone receives Carer’s Allowance for looking after you or your partner? If the answer is yes, please confirm the details below. Part 5 – Earnings from Employment Important Notes Page 4

Do you, your partner, or other adults in your property work for an employer? Please tell us the name of your Yes employer, if you are employed. If No you have more than one job, please tell us about all of them. If you do You not have enough room, please use a Name of employer Start Date Gross Amount Net Amount No of Hours separate sheet of paper.

£ £ You need to provide your most recent wage slips for your £ £ employment, either your latest 4 £ £ weekly, 2 monthly, or 2 4/weekly wage slips. Your Partner Please give details of your Name of employer Start Date Gross Amount Net Amount No of Hours partner’s job(s) as well as your

£ £ own, and for any other adults who live with you. £ £ We also need to know how £ £ many hours per week on Other Adults average you work.

Name of employer Name of Adult Start Date Gross Amount Net Amount No of Hours

£ £

£ £

£ £

£ £

IMPORTANT - Please ensure you confirm the number of hours you work each week, as this can make a financial difference to the Council Tax Support awarded. Important Notes Page 5 Part 6 – Earnings from Self-Employment

If you are Self Employed, we Are you, your partner, or other adults in your property Self-Employed? will need to know the nature of your business, when you Yes started trading as a company, No your average number of hours worked per week and your You Gross Profit. Nature of Business Start of Trading Gross Profit Hours Worked

You must send us your trading £ accounts for the last financial year. We are able to provide £ a self-employed earnings £ declaration form for people who are unable to provide £ accounts. Please contact us for a form. Your Partner

Nature of Business Start of Trading Gross Profit Hours Worked If you have only recently set up business and do not have a full £ year’s accounts, we will need to see some other evidence of £ income, such as estimated earnings. We will write to you £ about this. £

Other Adults Adult Name Nature of business Start of Trading Gross Profit Hours Worked

£

£

£

£

Part 7 – Savings, Capital, Investments, Land and Property Important Notes Page 6

Please give details of all savings including cash, current bank accounts, investments, shares, You need to provide proof of all property or land owned by you or your partner. If none, please write “none”. savings, investments, shares, property or land owned by you or If you receive Universal Credit or Guarantee Credit, you do not need to fill out your partner. this section. This includes land or property in the UK or another country. You Details of type of account or investment, number of shares & Amount/Value This includes: address of land/property Cash

£ Bank accounts Building Society accounts

£ Post Office accounts £ Premium Bonds £ Stocks and Shares TESSAs £ ISAs Your Partner PEPs Details of type of account or investment, number of shares & Amount/Value Fixed term investments address of land/property National Savings Certificates

£ This is not a full list. You or your £ partner may have other types of £ savings or investments and you must tell us about all types of

£ savings, investments, shares, £ property or land that are owned If you or your partner’s savings, capital, investments, shares, property or land have changed, by you or your partner. please tell us the date of the change and details of the change.

Important Notes Page 7 Part 8 – Backdating your claim

Regulations allow us to Please state the date that you wish to claim Council Tax Support from. consider backdating your claim, for a maximum of one month from the date you hand this form in e.g. if you provide this form on 1st February, we From this earlier period, were your circumstances the same as on this form? can consider backdating your Yes claim to the 1st January. We would look to pay your claim No from the Monday following this date. If your circumstances were different, please give us details as to why they were different.

Please include as much detail as you can for your reasons for not claiming sooner.

You should provide any supporting proof that you think will help with your request e.g. a doctor’s letter, or a letter from the hospital. Please give details as to why you did not make a claim earlier. Please see the important notes to the left for what information you should look to include below.

Part 9 – Other Information Important Notes Page 8

Please use this space to tell us anything else you think we should know about. This could be You should include any information to support your claim, or anything you feel will aid us in making a quicker information on this page that you decision. feel may assist us with making a decision on your claim.

This can be any future changes that may happen, that could affect your claim.

You should provide proof of this where possible. Important Notes Page 9 Part 10 – Your Declaration

How we collect and Please read this declaration carefully before you sign and date it use information I declare that the information I have given on this form is correct and complete. Where I have provided information about other people on this form, I have explained to them that We will use the information you give us I have done this, explained to them what you will use their information for and obtained on this form, and any supporting their consent to those uses. By signing this form, I am confirming that I have done this. evidence you send, to process your claim I understand that if I do give information that is incorrect or incomplete, you may take for Council Tax Support. We may pass action against me. This includes court action the information on to other agencies or organisations such as the Department for I agree that you will use the information I have provided to process my claim for Housing Work and Pensions, HM Revenue and Benefit, Council Tax Support or both. You may check some of the other information with Customs and The Pensions Service, as other organisations as allowed by law allowed by law. I understand that you may use any information that I have provided in connection with We may check the information you have this and any other claim for social security benefits that I have made or may make. You provided, or information about you that may give some information to other organisations such as government departments, local someone else has provided, with other authorities and private-sector companies such as banks and organisations that may lend information that we hold. me money, if the law allows this We may also get information about you from certain third parties, or give I know that I must let the Benefits Service know in writing about any changes in information to them to: circumstances, which might affect my claim • Make sure the information is accurate • Prevent or detect crime, and • Protect public funds. Your Your Partner's These third parties include government Signature Signature departments, other local authorities and private companies such as banks and Date Date other organisations that may lend you money. We will not give information about Please use a separate sheet(s) to tell us about anything that you did not mention or did not you to anyone else, or use information have enough room to put elsewhere on this form. about you for other purposes, unless the law allows it. If you are sending separate sheet(s) with this form please tick this box The Council is the data controller for the purpose of the Data Protection Act. If you want to know more about what information we have about you, or the way that we use that information please write to the Data Protection Officer at the address on the front of this form.