Cannock Chase Stafford A claim form for Housing Benefit District Council Borough Council Civic Centre Civic Centre (including Local Housing Allowance) PO Box 28 Riverside Beecroft Road Stafford and Local Council Tax Support Cannock ST16 3AQ Staffordshire WS11 1BG Working Together Housing Benefit direct number: 01543 464292 or 01785 619478 Name, address and postcode Date issued Date received Claim reference number Property reference number Office use only Please quote this number if you write to or phone us. Please fill this form in black pen only. Please answer every question. Are you: an owner-occupier? a council tenant? a housing association tenant? a private tenant Please tick the appropriate box. Notes to help you fill this form are attached to the back. Please read them. Part 1 About you and your partner Do you have a partner who normally lives with you? A partner is a person you are married to or have a civil partnership No with, or a person you live with as if you were their husband, wife or civil partner. (A civil partnership is a formal arrangement that gives Yes If you have a partner, you must answer all the same-sex partners the same legal status as a married couple.) questions about them, as well as yourself. You Your partner Surname or family name Other names Any names you have used in the past Title (Mr, Mrs, Ms, and so on) Address, including the room number if you have one Do not tell us your partner’s address if it is the same as yours. What date did you move to this / __ __ / / __ __ / address? Your daytime phone number Giving us your phone number will reduce delays in processing your claim E-mail address Date of birth / __ __ / / __ __ / Letters Numbers Letter Letters Numbers Letter National Insurance number You can find this on payslips or letters from the Department for Work and Pensions or HM Revenue & Customs. If you do not have National Insurance If you do not have National Insurance We cannot normally decide your claim if number, or cannot find it, tick this box. number, or cannot find it, tick this box. we do not have your National Insurance number. We need to see proof of this. How did you find out about how to claim benefit Part 1 About you and your partner Page 2 You Your partner Have you or your partner claimed No No Housing Benefit (including Local Housing Allowance) or Local Yes Yes Council Tax Support? Please tell us about it below Please tell us about it below When did you last claim? / __ __ / / __ __ / Which council did you claim from? What name did you use for the claim? What address did you claim for? If you have moved from this No No address, have you told the council you claimed from? Yes Yes If you or your partner have moved home in the last 12 months, tell us your last address (if it is different from above). Tell us whether you were the homeowner, a private tenant, a council tenant or a lodger at this address. We need to see proof of your identity and National Insurance number. See the checklist at part 14. Have you or your partner come to No No live in England, Northern Ireland, Scotland, Wales, the Republic of Ireland, the Channel Islands or the Yes We will write to you about this. Yes We will write to you about this. Isle of Man in the last two years? What is your nationality? If your nationality is not British, / __ __ / / __ __ / on what date did you last enter and apply to stay in the UK? The UK is England, Northern Ireland, Scotland and Wales. Are you or your partner in No No hospital at the moment? Yes Please tell us about it below. Yes Please tell us about it below. When did you go in? / __ __ / / __ __ / When will you come out, if you / __ __ / / __ __ / know this? Do you or your partner get No No Disability Living Allowance or Personal Independent Payment (PIP)? Yes How much? Yes How much? Care £ Care £ Mobility £ Mobility £ Daily Living Daily Living £ £ Rate Rate Part 1 About you and your partner continued Page 3 You Your partner Do you or your partner get No No Attendance Allowance? Yes We will write to you about this.Yes We will write to you about this. Does anyone get Carer’s No No Allowance for looking after you or your partner? Yes We will write to you about this.Yes We will write to you about this. Have you or your partner been No No told that you are entitled to Carer’s Allowance, even if you Yes We will write to you about this.Yes We will write to you about this. do not receive it because you are getting another benefit instead? Do you or your partner pay No No towards supporting a student? Yes How much do you pay and Yes How much do you pay and how often? how often? £ every £ every Are you or your partner a student? No No By student we mean anyone Tell us if this is full-time or part-time. who is on a course of study at Yes Yes Tell us if this is full-time or part-time. an educational establishment, including student nurses. Full-time Part-time Full-time Part-time How much of your income is taken into £ a year £ a year account when working out your grant? Please tick if you, or your partner: • are an apprentice • are on youth training • are in legal custody • have a severe learning disability, mental illness or form of dementia • are registered blind • are long-term sick or disabled Do you or your partner have a vehicle No No from the Mobility Scheme? Yes Yes We will contact you if we need any more information. Part 2 About children Page 4 We need to know about any children in your household who are: • under 16; • aged 16 or 17 and registered for work or youth training; or • aged 16, 17, 18 or 19 and in education doing a course not higher than GCE A-level, SCE Higher level or GNVQ (advanced). Are there any children in your household as described above? No Go to part 3. If there are more than three children, use a separate sheet Yes of paper to tell us all the information we ask for on this page and send it with the form. If you are sending a separate sheet of paper, tick this box. First child Second child Third child Last name Forename Date of birth / __ __ / / __ __ / / __ __ / What is the child’s sex? The child’s relationship to your partner Usual address, if different from yours Child Benefit number Who gets the Child Benefit for them? We need to see proof of this. Do you receive No No No maintenance for any of these children? Yes Yes Yes If so, how much? £ £ £ How often? £ £ £ Is the child registered No No No blind? Yes We need to see Yes We need to see Yes We need to see proof of this. proof of this. proof of this. Does the child get No No No Disability Living Allowance or Personal Yes How much? Yes How much? Yes How much? Independent Payment (PIP)? Care £ £ £ Mobility £ £ £ Daily Living Rate £ £ £ Do you or your partner pay any childcare No No No costs for this child to a Please tell us about it Please tell us about it Please tell us about it registered childminder, Yes Yes Yes below. below. below. a nursery or an after-school club? Tell us the name and registration number of the childcare provider. How much do you pay £ a week £ a week £ a week each week? We need to see proof of this. We need to see proof of this. We need to see proof of this. Part 3 About other people who live with you Page 5 Now tell us about all the people who usually live with you and your partner. Do not tell us about people who just share a hall, bathroom or toilet with you. Do any adults usually live with you and your partner? Yes No (People over 16 who nobody gets child benefit for) If you are sending a separate sheet of paper, tick this box. First person Second person Third person Last name Forename Date of birth / __ __ / / __ __ / / __ __ / Their relationship to you or your partner Some examples are aunt , brother, daughter, father, grandson, grandmother, stepdaughter, joint tenant, owner, subtenant, lodger, boarder or friend. Do they get Income No No No Support, income-based Yes Yes Yes Jobseeker’s Allowance or the guaranteed part of Pension Credit? Do they get Disability No No No Living Allowance or Attendance Allowance Yes How much? Yes How much? Yes How much? or Personal Independent Payment (PIP)? £ a week £ a week £ a week Are they registered No No No blind? Yes Yes Yes Are they a full-time No No No student, a student nurse, a care worker, Yes Tell us which. Tell us which.Yes Tell us which. an apprentice or on Yes youth training? Do they pay rent or £ a week £ a week £ a week money for board and lodgings to you or your partner? Does this include No No No money for meals? Yes Which ones? Yes Which ones?Yes Which ones? Breakfast Lunch Breakfast Lunch Breakfast Lunch Evening meal Evening meal Evening meal Does this include No No No money for heating? Yes Yes Yes Do they have a severe No No No learning disability? Yes Yes Yes Are they in legal No No No custody at the When are they When are they When are they moment? Yes expected to come out? Yes expected to come out? Yes expected to come out? / __ __ / / __ __ / / __ __ / Are they in hospital at No No No the moment? Yes Tell us about it below.