Council Tax Support and Housing

Benefit Claim Form

Don’t delay - claim today!
Please return this form as quickly as possible, even if you do not have everything we ask for, to make sure that
you do not lose any benefit.
You can send the rest to us later.

Filling in the form

· Use blue or black ink to fill in the form. Do not use pencil. If you make a mistake, just cross it out and put
the right answer next to it. Do not use correction fluid or tape. Please initial any alterations.
· Answer ‘Yes’ or ‘No’ questions by ticking 3 the relevant box. If you are picking an answer from a list of
answers, put a tick in the relevant box. If you do not answer a question we will have to send the form
back, and this will delay the claim.
· If someone else fills in the form for you, there is a declaration for them to sign in Part 16. You must sign
Part 16 as well.
· Your award will normally start from the Monday after we receive the form. In the form, we ask for proof
of your income and capital. If you don’t yet have all the proof we need, send the form in now and send
the proof later.
You have one month from the date we receive the form to send in the proof.
· You must tell us immediately if your circumstances change. See page 2 for a list of changes that may
affect your claim.

How to contact us in writing:

· Benefit Section, Dacorum Borough Council, The Forum, Marlowes, Hemel Hempstead, Herts, HP1 1DN

· Or in person by visiting the Customer Service Centre at The Forum

Monday to Thursday 8.45am – 5.15pm, Friday 8.45am – 4.45pm.
Phone:01442 228000 and ask for “Benefits”
Email: benefits@dacorum.gov.uk

If you cannot get out easily and need help filling in the form, we can come out and help you.
Please contact us on the number above.

For office use only

Date of issue
Date Received

Issued by
Notes for filling in the claim form
About this form
This Council Tax Support and Housing Benefit claim form has been specially designed to be easy to fill in. It is
long,
but we have to ask a lot of questions to make sure that everyone who claims gets the right amount of award.
You may not have to fill in all parts of the form, but you must fill in any part that is relevant to you. Every
part starts with a question to help you decide if you need to fill in that part.

Second Adult Rebate

Second Adult Rebate is Council Tax Support you can get if you are a pensioner, share your home with
someone who is not your partner, is on a low income, is 18 or over, and does not pay you rent.
If you are claiming Second Adult Rebate, only fill in Parts 1, 3, 13 and 15.

Evidence
We need to see evidence of some of the things you tell us about. The checklist at the end of the form will
help you. If you are not sure if we need to see evidence of something, get in touch with us. We will tell you
what we need to see. We cannot pay your award until we have seen the evidence we have asked for.

How we collect and use information

We will use the information you give in this form, and in any supporting evidence you send us, to process
your claim for Council Tax Support and Housing Benefit.
We may pass the information to other agencies or organisations such as the Department for Work and
Pensions and HM Revenue and Customs, as allowed by law. We may check information you have provided,
or information about you that someone else has provided, with other information we hold. We may also get
information about you from certain third parties, or give them information, to:
• make sure the information is accurate; and
• prevent or detect crime; and
• protect public funds.
These third parties include government departments, local authorities and private-sector companies such as
banks and organisations that may lend you money.
We will not give information about you to anyone else, or use information about you for other purposes,
unless the law allows us to.
The Council is the data controller for the purposes of General Data Protection Regulations/ UK Data Protection
Bill. If you want to know more about what information we have about you, or the way we use it, please visit
www.dacorum.gov.uk/privacypolicies

Changes you must tell us about Tell the Council's Benefit Department straight away if;
• any of your children leave school or leave home; or
• anyone moves in or out of your home (including lodgers, joint tenants and subtenants); or
• your income or the income of anyone living with you, including benefits, changes; or
• your capital, savings or investments change; or
• you or anyone living with you becomes a student; goes on a Youth Training Scheme; goes into hospital or a
nursing home; goes into prison; or gets, changes or leaves a job; or
• you or your partner are going to be away from home for more than a month; or
• you receive any decision from the Home Office; or
• anything you have told us about changes; or
• you move house; or
• you or any one in your household receives or ceases to receive DLA or PIP.

If you don’t tell us about these changes, you may lose money you are entitled to or you may be paid
too much benefit or support.

You must make sure that you tell us about these changes. Don’t rely on someone else to pass on the message.
It is an offence not to tell us about any change of circumstance that affects your award. We may take
court action against you. If we pay you too much support, in most cases, you will have to pay it back.
page
 page 3
Council Tax Support and
Housing Benefit Claim Form

Part 1 About you and your partner

Do you have a partner who
normally lives with you? X
A partner means a person you No
are married to or have a civil
partnership with, or a person you Yes
live with as if you were their
husband, wife or civil partner.
(A civil partnership is a formal
arrangement that gives same sex
partners the same legal status as
a married couple.) Even if your
If you have a partner, you must answer all the questions about
partner only comes home at
weekends, or part of the week, them, as well as yourself.
you must include them You Your partner
Surname or family name Walter

First name(s) David

Any other surnames or family

names you have used, such as
before marriage or in a
previous marriage
Title (Mr, Mrs, Ms and so on)
Mr

Address 15 Wellington Court

Do not tell us your partner’s
St albans Hill
address if it is the same as yours.

Postcode HP3 9NQ Postcode

What date did you move in to 06 07 2015
this address? (first spent the / / / /
night there)
Your daytime phone number 07915959676
You do not have to tell us this,
but it may help us to deal with
your claim more quickly.
What is this number? X
Home Work Mobile Textphone Home Work Mobile Textphone
Please tick.
E-mail address
krsnatab@gmail.com
We want to deal with your claim
as quickly as we can and if we
have your e-mail address we may
contact you this way.
Date of birth 14 / 12 / 19983 / /
Letters Numbers Letter Letters Numbers Letter
National Insurance number 7 4 b
j s 9 4 2
You can find this on payslips or 3
letters from Department of
Works and Pensions or the If you do not have a National If your partner does not have a
tax office. We can decide your Insurance number, or cannot find it, National Insurance number, or
claim only if we see evidence cannot find it, tick this box.
that this is your National tick this box.
Insurance number (see part 13).
We must see evidence of you and your partner’s identity and National Insurance number.
Read the checklist in part 17.
Part 1 About you and your partner – continued page 4

No X
Are you living away from
home at the moment?
Yes Tell us why you are not living at home.

When did you last live at home? When do you expect to go back home?
/ / / /
Tell us the address where you are living at the moment.

Postcode
If your home has been sublet, tell us who lives there now.

You Your partner

Have you or your partner
claimed Council Tax Support, No No
Housing Benefit or Council Yes X When did you claim? Yes When did they claim?
Tax Benefit before?
02 05 / 2021
/ / /
Which council did you claim from? Which council did they claim from?
Dacorum

What name did you claim in? What name did they claim in?
David Walter
What address did you claim for? What address did they claim for?
15 wellington court

hp3 9nq
Postcode Postcode

If you have moved home in

the last 12 months, tell us
your last address.

Postcode Postcode
Were you the home owner, Home owner
a private tenant, a council
tenant or a boarder at this
address?
Have you or your partner
come to live in England, X
No No
Northern Ireland, Scotland,
Wales, the Republic of Ireland, Yes We will write to Yes We will write to
the Channel Islands or the Isle you about this. you about this.
of Man in the last 2 years?
What is your nationality? British

If your nationality is not / / / /

British, on what date did
you settle in the UK (please
don’t include times when you’ve
been on holiday outside of the UK)?
The UK is England, Northern Ireland,
Scotland and Wales.
Part 1 About you and your partner – continued page 5

You Your partner

Are you or your partner in X
No No
hospital at the moment?
Yes When did you go in? Yes When did they go in?
/ / / /
When will you come out When will they come out
(if you know this)? (if they know this)?
/ / / /
Do you or your partner get X
Disability Living Allowance? No Yes No Yes

Do you or your partner get

No X Yes No Yes
Personal Independence
Payment?

Do you or your partner get

No X Yes No Yes
Attendance Allowance?
Does anyone get Carer’s X
No Yes No Yes
Allowance for looking
after you or your partner? (If anyone claims Carer’s Allowance for looking after you in the future please let us know)
Have you or your partner ever No X Yes No Yes
claimed Carer’s Allowance?
Still tick ‘Yes’ if you claimed but
were not paid any money.

Do you or your partner have X

No Yes No Yes
a vehicle from a mobility
scheme?
Are you or your partner a No X Yes No Yes
student?
Do you study full time or part time? Do they study full time or part time?

Full time Part time Full time Part time

Tick if you or your partner are:
• an apprentice X

• on youth training X

• in legal custody X

• severely mentally impaired X

• registered blind X

• long-term sick or disabled X

Is anyone in the household No X Yes

pregnant?
If ‘Yes’, who? Due Date / /
Part 2 About children page 6

Are there any children in your

household? By children we mean No X Go to Part 3.
under 16 or aged 16 to 20 and in
Yes If there are more than 4 children, use a separate sheet of paper to tell
full-time education or approved
us all the information we ask for on this page.
training.
If you are sending a separate sheet of paper, tick this box.

First child Second child Third child Fourth child

Surname or family name

First name(s)

Date of birth / / / / / / / /

What is the child’s sex?

The child’s relationship to you

The child’s relationship to your

partner
Usual address if different
from yours

Child Benefit number

Who gets the Child Benefit

for them?
F
Is the child registered blind? No Yes No Yes No Yes No Yes

Does the child get Disability No Yes No Yes No Yes No Yes

Living Allowance?
Does this child get No No No No
Personal Independent
Payment? Yes Yes Yes Yes

Do you pay a registered No No No No

childminder, nursery or
after-school club any Yes Yes Yes Yes
If yes, please tell us the If yes, please tell us the If yes, please tell us the If yes, please tell us the
childminding costs for this name and registration name and registration name and registration name and registration
child? number of the childcare number of the childcare number of the childcare number of the childcare
provider. provider. provider. provider.

How much do you How much do you How much do you How much do you
pay a week? pay a week? pay a week? pay a week?
£ £ £ £
 Part 3 About other people who live with you page 7
Do any adults usually live with No X Go to Part 4.
you and any partner you have?
Yes Answer all questions in this section.
By adults we mean people over 16 who nobody gets Child Benefit for. Do not tell us about people who just share a hall,
bathroom or toilet with you. If you want to tell us about more than 3 people, use a separate sheet of paper.
If you are sending a separate sheet of paper, tick this box.
First person Second person Third person
Surname or family name

Other names

Date of birth / / / / / /

National Insurance Number

Their relationship to you or
your partner Some examples are
aunt, brother, daughter, father, grandson, grandmother, stepdaughter, joint tenant, joint owner, subtenant, lodger or friend.
When did they move in? / / / / / /
Do they receive any No No No
State Benefits?
Yes Tell us which. Yes Tell us which. Yes Tell us which.

Do they normally work? No No No

Yes Please tell us their Yes Please tell us their Yes Please tell us their
gross earnings and gross earnings and gross earnings and
number of hours number of hours number of hours
they work they work they work

Are they a full-time student, No No

No
a student nurse, a care
worker, an apprentice or on Yes Tell us which. Yes Tell us which. Yes Tell us which.
youth training?

Are they severely No No No

mentally impaired? Yes Yes Yes

Are they in legal custody No No No

at the moment? Yes When are they Yes When are they Yes When are they
expected to be expected to be expected to be
released? released? released?
/ / / / / /

Are they in hospital No No No

at the moment? Yes When did they Yes When did they Yes When did they
go in? go in? go in?
/ / / / / /
When will they come out When will they come out When will they come out
(if you know this)? (if you know this)? (if you know this)?
/ / / / / /
Are any of the people who No
live with you married to
Yes Tell us their names.
each other, civil partners is the
of each other, or living partner of
together as if they are And
married or civil partners? is the
partner of
Part 4 About Income Support, income-based Jobseeker’s Allowance, page 8

Pension Credit (Guaranteed Credit) and Employment and

Support Allowance (income-related)
You Your partner
Are you or your partner getting
No No
Income Support, income based
Jobseeker's Allowance, Pension Yes X When did you start Yes When did they start
Credit (Guarantee Credit) or getting it? getting it?
Employment and Support Allowance 01 / 04 / 2023 / /
(income related) at the moment?
Are you or your partner still
waiting to hear about a claim for No X No
Income Support, income-based
Jobseeker’s Allowance, Pension Yes When did you claim? Yes When did they claim?
Credit (Guarantee Credit) or / / / /
Employment and Support Allowance
(income-related)?
Part 5 About benefits, tax credits and state pensions
Are you or your partner getting any of the benefits or credits listed
below, or are you waiting to hear about benefits or credits you have No ?
X Go to Part 6.
claimed? Read the list of benefits and credits below and tell us about
any that you or your partner are getting now or have claimed. Yes ? Tell us about the benefits
below.

You Your partner

Yes How much How often Yes How much How often
Pensions do you get? is it paid? do they get? is it paid?

State Retirement Pension £ £

Pension Credit (Savings Credit) £ £
Widow’s Allowance or
Bereavement Allowance £ £
Widowed Parent’s Allowance
or Widow’s Pension £ £
War Widow’s or War
Dependant’s Pension £ £
War Disablement Pension £ £
Industrial Injury/Disablement
Pension £ £
Exceptionally Severe £ £
Disablement Allowance
Benefits and Allowances
Contribution-based Job
Seeker’s Allowance £ £
Child Tax Credit £ £
Working Tax Credit £ £
Employment Training Allowance £ £
Child Benefit £ £
Incapacity Benefit £ £
Employment and Support
Allowance - contribution based £ £
Attendance Allowance £ £
Disability Living Allowance:
Mobility Component £ £
Care Component £ £
Part 55
Part About benefits,tax
About benefits, taxcredits
creditsand
andstate
statepensions
pensions page 9

You Your partner

Personal Independence Payment £ £
Carer’s Allowance £ £
Severe Disablement Allowance £ £
Maternity Allowance £ £
Fostering Allowance £ £
Universal Credit £ £
Any other benefit, pension or £ £
money from the government

Are you repaying a Social Fund

No Yes If yes, which one?
loan or overpayment for any of
these benefits?
Have you or your partner No Yes If yes, please give details
deferred (put off) receiving a
pension?

Part 6 Income other than earnings

Do you or your partner have any money coming in (or expect to No X Go to Part 7.
have some money coming in) that you have not already told us
Yes Complete the questions as below.
about on this form?
You do not need to tell us about payments from the Independent
Living Fund, the Eileen Trust or the Macfarlane Trust.
You Your partner
Yes How much How often Yes How much How often
Private Pension 1 paid by do you get? is it paid? do they get? is it paid?
£ £

Private Pension 2 paid by Date of next increase / / Date of next increase / /

£ £
Please attach separate sheet ifyou have more than 2 pensions
Date of next increase / / Date of next increase / /
Pension Protection Fund
Payments £ £
Annuities £ £
Youth Training Scheme
£ £
payment or Training Credits
Maintenance for you £ £
Maintenance for your child
- including CSA £ £
Student grant or loan £ £
Payments from boarders £ £
Weekly amount from letting
or sub-letting part of a property £ £
Payments from a charity £ £
Any other income e.g. Redundancy
or Loan Protection Payments £ £
(please give name)

We must see evidence of any money or pension coming in before we can decide how much Support you can get.
Read the checklist at Part 17 to see what you can use as evidence.
Part 7 About working for an employer page 10

You Your partner

Do you or your partner work for No X Go to Part 8. No Go to Part 8.
an employer?
Yes Answer the questions Yes Answer the questions
in this section. in this section.
Do you work for more than one No No
employer?
Yes Yes
Tell us about all the employers on a separate sheet of paper and send
it with this form. Include all the information asked for below.
If you are sending a separate sheet of paper, tick this box.

What kind of work do you do?

p
What is your employer’s
name and address?

Postcode Postcode

When did you start this job? / / / /

How much do you get paid
before tax and National £ £
Insurance are taken off?

How often do you get paid? Every Every

How are you paid?

For example, in cash, by cheque
or straight into a bank or building
society account.
How many hours a week do you
usually work?
Give details of any regular
overtime, bonuses, commission
or tips.
Are you getting Sick Pay, No No
Maternity Pay, Paternity Pay or
Adoption Pay from your employer Yes Yes
at the moment?
When did it start? / / / /
Do you pay into a private or No No
company pension scheme?
Yes How much? Yes How much?
£ £
How often? How often?
Every Every

We must see 5 weekly, 3 fortnightly or 2 monthly consecutive of your most recent pay slips before we can
decide how much Support you can get. Read the checklist at Part 17 to see what you can use as evidence.
Part 8 About being self-employed page 11

You Your partner

Are you a company director? X Yes
No No Yes
If you answered ‘Yes’, you will
need to provide your payslips.

Are you or your partner No ✟X Go to Part 9. No ✟ Go to Part 9.

self-employed?
Yes ✟ Answer the questions Yes ✟ Answer the questions
on this page. on this page.
You must send us your trading accounts for the last financial year.
If you have only recently set up the business and do not have a full year’s accounts,
we will need to see some other evidence of your income.
p p p We will write to you about this.

What kind of work do you do?

When did the business start? / / / /

What is the business address?

Postcode Postcode
Are there any other partners No Yes Tell us their name No Yes Tell us their name
in the business? and address. and address.

Postcode Postcode
How many hours a week
do you usually work?
Do you get a Business No Yes How much? No Yes How much?
Start-up Allowance?
£ £
How often? How often?
Every Every

Do you pay into a private No Yes How much? No Yes How much?
pension scheme?
£ £
How often? How often?
Every Every

We must see evidence of your earnings before we can decide how much Support you can get. Read the checklist
at Part 17 to see what you can use as evidence.
Part 9 About any other work page 12

You Your partner

Do you or your partner do No X Go to Part 10. No Go to Part 10.
any other work?
This could be voluntary work, Yes Answer the questions on Yes Answer the questions on
therapeutic work or any other this page. this page.
work.
What other work do you do?

What is the name and

address of the person you do
this work for?

Postcode Postcode
When did you start this work? / / / /

How many hours a week do

you usually work?

Do you get paid for this work ? No No

Yes How much? Yes How much?

£ £
How often? How often?
Every Every
We must see evidence of any earnings before we can decide how much Support you can get.
Read the checklist at Part 17 to see what you can use as evidence.

Part 10 About bank accounts, savings, investments and property

You Your partner
Do you or your partner have any
bank accounts, savings, property No Go to part 11 No
or investments in the UK or abroad? X
Yes Answer all the questions in this part. Yes
This includes cash, current accounts and savings accounts with a bank or building society, post office accounts,
Premium Bonds, National Savings Certificates, stocks, shares and property.

Please answer these questions for yourself and your partner. Please include empty and overdrawn accounts, whether
in one name or jointly held with anyone else. Your Partner's
Account number/name/other details balance/value balance/value
15665741 £ 35.52 £
Do you have bank, building No
society or post office accounts? X £ £
Yes
(including current accounts)
£ £
If yes, please tell us the balance
of your accounts £ £
£ £
£ £
£ £
£ £
N
We may ask to see evidence of all capital, savings and investments. Read the checklist at Part 17 to see what you
can use as evidence.
D
Part 10 About bank accounts, savings, investments and property page 13

Name Number held

Do you have stocks, shares, No X

unit trusts?
Yes
If yes, list the names of
investments and number of
shares held.

Do you have National No X

Savings Certificates?
Yes
If yes, list the issue, purchase
date and number of units.

Do you have other No X

investments, redundancy
payments, premium bonds, Yes
Tessas, ISAs, SAYE, cash etc?
If yes, please give details.
(Please also use this space if
you need to tell us more about
any of the above savings.)

Have you or your partner X

No Yes If ‘Yes’ please give details.
received any backdated
benefit or deferred
payments, such as State
pension, which you have
added to your savings?

Do you or your partner own No X Yes What is the address?

or partly own any property or
land except the home you live in,
either in the UK or abroad?
Tick ‘Yes’, even if you have a
mortgage or loan for the
property or land. This includes
jointly owned properties. Postcode

How much is it worth? £

If you have a mortgage or loan for

£
this, how much is left to repay?

Have you or your partner No X Yes

received a compensation
payment relating to the
Second World War?
Part 11 About rent page 14

Do you rent your home? No X Go to Part 15.

Tick ‘Yes’ if you would pay rent Yes Answer all the questions in this section.
but already get Housing Benefit.
How much is the rent for £
your home? every
(For example, every week/fortnight/4 weeks/month.)
What date did your tenancy start? / /

I authorise the Council to discuss my claim or benefit award

May we discuss your claim or with my landlord
No or
benefit award with your landlord
or another named third party? Yes
Signed Date

What is your landlord’s

name and address?
By landlord we mean the person
or organisation who owns the
property you live in.
Postcode
If your landlord has an agent, tell
us their full name and address.
By agent we mean the person or
organisation you actually pay your
rent to.
Postcode

Are you, your partner, or any of No ✟

your or your partner’s children
related to your landlord or agent, Yes ✟ What is the relationship?
or to your landlord’s partner or is my landlord’s
the agent’s partner? or agent’s
Related means a parent, parent-in-law, son, son-in-law, daughter, daughter-in-law, step-parent, step-son, step-daughter,
brother, sister, or if any of the preceding persons is one member of a couple, the other member of that couple;
Are you or your partner a director, No
shareholder or employee of your
landlord? Yes
Have you or your partner owned No
your current home in the last 5
years? Yes
Does anyone else share the
No
rent with you and your
partner? Yes Tell us their names and their relationship to you and your partner.

How much of the rent do you pay?

£
every
(For example, every week/fortnight/4 weeks/month.)
Are you a care leaver or formally No
looked after by social services?
Yes
Part 11 About rent – continued page 15

Who is liable for council tax

at this address?

Has your rent been registered No ✟ Yes ✟

as a fair rent by a rent officer?
Are there any weeks when No ✟ Yes ✟ How many in a year?
you do not have to pay rent?

Are you behind with your No ✟ Yes ✟ By how many weeks?

rent?

Does your rent include

money for the following?

Meals No ✟ Yes ✟ Which meals are included? All ✟ Breakfast ✟ Evening ✟

Water authority charges No ✟ Yes ✟
Heating No ✟ Yes ✟
Lighting No ✟ Yes ✟
Hot water No ✟ Yes ✟
Fuel for cooking No ✟ Yes ✟ What is it?
Is anything included or
separate from your rent
that you have not already
told us about?

Please tick to show if the

property is let as:
furnished ✟ This means completely furnished.

partly furnished ✟ This means some furniture, but not all.

minimally furnished ✟ This means just two or three items.

unfurnished ✟ This means no furniture at all.

Part 12 About where you live

What sort of building do you
live in? Tick one box only.
Detached house Flat in a house Caravan, mobile
✟ ✟ home or houseboat ✟
Semi-detached house ✟ Flat in a block ✟ Board and lodgings ✟
Terraced house ✟ Flat over a shop ✟ Hotel ✟
Residential nursing
Maisonette ✟ Bedsit or rooms ✟ home ✟
Bungalow ✟ Hostel ✟ Residential care home ✟
Detached Bungalow ✟ Ground rent ✟
Other (please say what)
a
Part 12 About where you live - continued page 16

How many rooms are there in In the whole Just for you and That you share with
the building? building? your household? other people?

Living rooms

Bedsitting rooms

Bedrooms

Bathrooms or shower rooms

Separate toilets

Kitchens

Other rooms

What are these other rooms?

Do you have a bedroom which is No
used overnight by someone who
cares for you or your partner but Ye s Their name and address
does not live at your address?

Do you use your No

home for business purposes? Postcode
Yes
Do you have a main home No
somewhere else?
If your main home is Yes What is the address?
somewhere else in the UK
or abroad, tick ‘Yes’, even if
you do not pay rent for it.

Postcode

Part 13 How you will be paid and the choices you have.

We will write to you about your benefit award.

Enter your email address if you want to be contacted in this way

• If you pay rent to a private landlord we will pay any benefit directly to you. If you feel this will cause you difficulties., please
call 01442 228000 for advice. Email: housing.benefits@dacorum.gov.uk
• If you are awarded Council Tax Support, we will pay this into your Council Tax Account.

If you do not have a bank or building society account you must set one up. You can get advice about opening and running a
bank or building society account from any bank or building society of your choice. If you have any difficulties in opening one
of these accounts please contact us on 01442 228000 for advice. Under the Local Housing Allowance Scheme you will have
your Housing Benefit paid directly to you (unless you are considered by us to have difficulty in managing your financial
affairs). You will be informed in writing when this will take effect.
Part 13 How you will be paid and the choices you have - continued page 17

Please remember it is your responsibility to pay your landlord.

To accept direct payments of Housing Benefit into your account please complete the following:

Name and address of the bank Account number

Sort code

Roll No.

Full Name (in

Account Name CAPITAL LETTERS)
Your Signature

Date / /

Part 14 Backdating
We can usually award benefit from the Monday after the day we get your claim. Sometimes, we can pay Housing Benefit and Council
Tax Support from an earlier date if you have a good reason for not claiming earlier. If you want us to consider paying your Housing
Benefit and Council Tax Support from an earlier date, tell us when you want Housing Benefit and Council Tax Support to be paid
from and provide reasons why you didn’t claim earlier in the box below. If you are a working age customer, you can request your
Housing Benefit claim to be backdated for up to one month and your Council Tax Support award for up to one month.
Tell us the date you want to
claim benefit from / /
 page 18
Part 15 Anything else you need to tell us
Use the box below to tell us anything else you think we should know about. Use a separate sheet of paper and
attach it to this form if you need to.
If you are sending separate sheets of paper with this form, tell us how many. X

Part 16 Declaration p

Even if someone else has partly or fully filled in this form for you, you MUST sign this declaration if you can.
If you have a partner, it would be helpful if they sign below to confirm that all the details about them are correct.
Please read this declaration carefully before you sign and date it.
I understand the following:
• If I give information that is incorrect or incomplete, you may take action against me. This may include court action.
• You will use the information I have provided to process my claim for Housing Benefit or Council Tax Support or both, or to
assess any discount or grant for Council services. You may check the information with other sources as the law allows.
• You may use any information I have provided for this and any other claim for social security benefits that I have made
or may make. This includes any Discretionary Housing Payment. You may give some information to other government
organisations, such as government departments and local councils, if the law allows this. The council may share data with
the government in order to combat fraud and reduce error and this includes the use of tracing agents.
I know I must let the Council's Benefit Section know immediately in writing about any change in my
circumstances or the circumstances of anyone living with me, which might affect my claim. If I do not, you may take action
against me. This may include court action.
I declare that this is my claim for Housing Benefit and/or Council Tax Support and the information I have given on this form is
correct and complete. I authorise the Council to make any necessary enquiries to check that the information is true and correct.
I have read and understood this declaration, and my responsibilities in reporting any changes in my circumstances to the
Council.

Signature of Date 27 / 03 / 23
person claiming
Partner’s
signature Date / /

If this form has been partly or fully filled in by someone who is not the person claiming, please tell us why you are
filling in this form for the person claiming.

As far as possible, I have confirmed with the person claiming that the answers I have written on this form are correct.
If I am making this claim on behalf of the above person, I understand that I am liable for what I have written on the form
and accept that the declaration applies to me.

Name of the person who filled in the form Signature of the person

Relationship to the person claiming

Date / /
 page 19

If you know or suspect someone is committing benefit fraud, you can report them direct without having to give your
name or details by:
• writing to the Council
• phoning: 01442 228291 - or National Hotline number 0800 854 440;
• e-mailing to FraudHotline@dacorum.gov.uk; or going on our website: www.dacorum.gov.uk

Part 17 Checklist
Please tick to tell us what evidence you are sending with this form. We must see original documents, not copies. If you
bring them to our Office, we will take the details we need and give you the documents back straight away.

If you do not provide all the evidence we need, we might not be able to pay you any support. We need the same
evidence for your partner, if you have one, and for any other adults living in your home.

If you cannot send the evidence we need at the moment, send the form back to us now and send the evidence later.
We can start to process your claim, but we will not be able to pay you any benefit until we have all the evidence.
Please tell us now in Part 15 if you cannot supply the evidence within one month.

• Evidence of identity - This is usually anything that has your full name and date of birth on it

• Evidence of your National Insurance Number - This could be any document that has your National Insurance
Number on it

• Evidence of your rent - This means a tenancy agreement or a rent account showing payments that you have made.

• Evidence of savings, investments and property - This means all of your bank accounts, savings accounts, shares,
premium bonds or other investments or property. We will need to see the last 2 months statements for any accounts.

• Evidence of earnings for all adults in the property – We need to see your payslips (your last 5 if you are paid week-
ly, your last 3 if you are paid every 2 weeks or your last 2 if you are paid monthly). If you are self-employed, you
will need to complete an additional form. Please contact us so that we can send you one.

• Evidence of other income – this means money from pensions or gifts of money that people have given to you.

• Evidence of benefits, Tax Credits or Pension Credit – any letters from the DWP or HMRC confirming how much you
get.

• Evidence of other money you pay out – this means receipts from registered child carers or financial help you give
to a student.

• If you would like us to discuss your claim with someone else who is helping you, you will need to complete a third
party authorisation form. Please contact us so that we can send you one.
Part 18 Ethnic Background
The government has asked us to gather information about our customer’s ethnic background. It’s your choice whether to fill
in this section. Please show which of the following groups you and your partner (if any) consider you belong to by ticking
one box for you and one for your partner.

You Your You Your

White partner Asian partner

British Asian British

Irish Bangladeshi
Other white Indian
Kashmiri
Mixed Pakistani
White and black Caribbean Other Asian
White and black African
White and Asian
by ticking
Other o
mixed Black British
Caribbean
A
British
Chinese African
Ban
Other black
Other
Other

Anything else you want to tell us about that may affect your claim