Discretionary Housing Payment Application Form - Carmarthenshire United Kingdom

ADVERTISEMENT
DISCRETIONARY HOUSING PAYMENT APPLICATION FORM
The Council have been granted very limited funds from which to make Discretionary Housing Payments. Therefore,
it is necessary for us to be able to assess your situation fully. In order to do this please complete this application and
answer all the questions. All information is treated in the strictest confidence.
NAME:
CLAIM No.
ADDRESS:
DATE OF BIRTH:
Telephone Number:
email address:
When did you move to this address
Are you renting from:
A private landlord
A Housing Association
the Local Authority
The rent on your home
£
week/month
1). How much rent are you charged per week/month?
2) Does this rent include any services, if so,
£
week/month
how much are these services
3)
After taking into account the amount of benefit you receive,
.
£
week/month
how much rent are you expected to pay each week/month?
4) Have you only recently had a shortfall of rent to pay?
Yes
No
If yes, from what date have you had to pay this shortfall ?
If no, have you been making up this shortfall ?
Yes
No
If ‘yes’, how have you paid for other things?
If ‘no’, is the landlord taking any legal action about the arrears?
5)
When is your tenancy agreement due to end
.
?
DISCRETIONARY HOUSING PAYMENT APPLICATION FORM
The Council have been granted very limited funds from which to make Discretionary Housing Payments. Therefore,
it is necessary for us to be able to assess your situation fully. In order to do this please complete this application and
answer all the questions. All information is treated in the strictest confidence.
NAME:
CLAIM No.
ADDRESS:
DATE OF BIRTH:
Telephone Number:
email address:
When did you move to this address
Are you renting from:
A private landlord
A Housing Association
the Local Authority
The rent on your home
£
week/month
1). How much rent are you charged per week/month?
2) Does this rent include any services, if so,
£
week/month
how much are these services
3)
After taking into account the amount of benefit you receive,
.
£
week/month
how much rent are you expected to pay each week/month?
4) Have you only recently had a shortfall of rent to pay?
Yes
No
If yes, from what date have you had to pay this shortfall ?
If no, have you been making up this shortfall ?
Yes
No
If ‘yes’, how have you paid for other things?
If ‘no’, is the landlord taking any legal action about the arrears?
5)
When is your tenancy agreement due to end
.
?
6) Is the shortfall due to any of the following reasons (please tick the relevant box)
Single and aged between 25 and 35 (private tenants only)
Local Housing Allowance rate does not meet the asking rent
Reduction in benefit due to the Social Sector Size Criteria (known as Bedroom tax)
(Housing Association and Local Authority tenants only)
Benefit Cap
For persons renting from a private landlord only
?…
…Yes
7a)
Have you tried to negotiate a lower rent with your landlord
.
No
If ‘yes’, please provide written proof of the outcome of this negotiation, if no proof available please state below
what was the result of the negotiation
.
If ‘no’, please give your reasons why you have not negotiated a lower rent with your landlord and provide details of
what contact you have made regarding this matter.
…Yes
7b)
Do you require assistance to negotiate with your landlord?
.
No
If yes, please provide contact details for your landlord and sign this box to confirm that you authorise this
department to contact the landlord on your behalf.
Signature
8) Have you recently moved to this property within the last 6 months
?
Yes
No
If no, please go to question 11, about your home
If yes please answer the following:
.
Why did you leave your previous address?
9).Did you make enquiries as to how much help you would receive at this address before moving in?
Yes
No
If not, why not?
If yes, please explain why you took on this tenancy knowing that there would be a shortfall to pay
Claim ref: ............
10). Did you or have you at any time during this tenancy contacted Housing Options (The Housing Department) to
…Yes
discuss how you would sustain this tenancy.
No
If yes, please provide details of whom you spoke to and the outcome of this discussion.
About your home – all claimants must answer this section
11)
Are there any reasons why you and your family have to live at this address rather than other cheaper
.
accommodation?
12)
When you first moved into your home could you afford to pay your housing costs without the help of
.
…Yes
benefit?
.
No
If ‘Yes’, please tell us about the change of circumstances which led you to apply for benefit.
13)
Has the property been adapted to suit the needs of a disabled person within your household?
.
…Yes
No
If ‘yes’, please give details of the adaptations
14)
Did you move into this property because of a disaster in your previous home such as fire or flood?
.
…Yes
No
If ‘yes’ tell us about the disaster below.
15) Do you require help with your current shortfall so that you can secure alternative accommodation? For
example the money you normally put aside for the shortfall will be used to secure cheaper accommodation.
…Yes
No
If yes, please provide details of the amount needed to secure the cheaper accommodation.
Claim ref: .......
About your family – all claimants must answer this section.
16). Does anyone in your family need extra care or
Yes
No
support because they are sick, elderly or disabled?
a) do you need an extra bedroom for a
Yes
No
non resident carer?
If yes, please provide details of who provides the care, how often this is provided and if you have a doctors
letter or formal care plan that would confirm these arrangements.
b) do you need an extra bedroom for a disabled child?
Yes
No
if yes, please confirm why this extra room is needed – we may also write to you for more information.
c) do you need an extra room because you and your partner are unable to share a bedroom due to your
disabilities?
Yes
No
If so, please provide a letter from your doctor to confirm this.
17). Has the number of occupants in your household
…Yes
changed in the last 12 months due to a bereavement?
No
If ‘yes’ please give details..
18)
Do you or your partner receive any of the following?
.
Disability Living Allowance
Mobility Allowance
Yes
No
Yes
No
Attendance Allowance
A war pension
Yes
No
Yes
No
Personal Independence Payments
Yes
No
…Yes
19)
Are you a registered Foster Carer?
No
If yes, do you
currently have any resident foster children?
Yes
No
If so, how many bedrooms do you need to accommodate the foster children.
If you have more than one foster child and they cannot share a bedroom please tell us why they cannot share
If you do not currently have any resident Foster children are you keeping an extra room available because
…Yes
you are in between foster children?
No
Claim ref: ...........
About your income and outgoings – all claimants must answer this section
20)
Please give details of all money coming in to your household. You must state the amount you receive
.
as well as the type of income
.
Weekly income
You
Your Partner
Net earnings from employment
£
£
Income Support or Job Seekers Allowance
£
£
Working Tax Credit or Child Tax Credit
£
£
Housing Benefit
£
£
£
£
Child Benefit
£
£
Pension Credit, State Pension or Works Pension
Any other state benefit
£
£
Money received from parents or friends
£
£
Any other income – please give source
£
£
£
£
Weekly expenses
Weekly
Arrears if any
Please change any monthly expenses to weekly figures
payments
Rent
£
£
£
£
Mortgage
Council Tax
£
£
Electricity
£
£
Gas
£
£
Water rates
£
£
£
£
TV licence and rental
Telephone
£
£
Food
£
£
Household products
£
£
Clothing
£
£
£
£
Car or public transport
£
£
Maintenance
Fines- court orders
£
£
social fund
Balance owing
Weekly repayments
Loans and other credit debts–
eg
loan
Assistance
/
, Catalogues, credit/store cards etc.
Name of lender
1
2
3
4
5
6
7
8
Please provide proof of these outgoings (ie. Letter from DWP, Last Catalogue Statement, Letter from Court) Failure to
provide proof will delay your application.
...........
Claim ref:

Download Discretionary Housing Payment Application Form - Carmarthenshire United Kingdom

124 times
Rate
4.8(4.8 / 5) 9 votes
ADVERTISEMENT
Page of 6