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Council Tax – Application for reduction on grounds of Severe Mental Impairment

IMAGE: The first page includes the Orkney Islands Council crest and the words “ORKNEY ISLANDS COUNCIL”.

To qualify for a reduction in the Council Tax on grounds of Severe Mental Impairment you must have a severe impairment of intelligence and social functioning, which appears to be permanent.

You must be entitled to one of the benefits in Part 2 and provide proof that you receive it. Your doctor must complete Part 4 and agree that you have a severe mental impairment.

Part 1 About you

Name __________________

Address ______________

________ Postcode ______

Part 2 Benefits that you receive

If you are entitled to any of the Benefits listed below you should tick the box, or boxes, that apply.

  • Incapacity Benefit
  • Employment and Support Allowance
  • Attendance Allowance
  • Severe Disablement Allowance
  • Care component of Disability Living Allowance paid at the highest or middle rate
  • Standard or enhanced rate of the daily living component of Personal Independence Payment;
  • An increase in the rate of disablement pension where constant attendance is needed
  • Disabled Persons Tax Credit
  • Unemployability supplement or allowance
  • Constant Attendance Allowance
  • Income Support (which includes a disability premium); or
  • has lost one of the above due to reaching pensionable age

You must provide proof of the benefit(s) that you are entitled to. Such proof may include a benefit award letter or proof of the benefit being paid into a bank account. All documents provided will be returned upon receipt.

Part 3 To be completed by the person applying for discount

Name of Doctor _________________

Address of surgery _____________

______ Postcode_______

Please turn over

IMAGE: The second page contains the continuation of the Council Tax application form, including the applicant’s declaration, contact details, Part 4 for completion by a registered medical practitioner, information-use notice, return address and official-use section.

Declaration - I declare to the best of my knowledge and belief that the information on this form is true and accurate and I will tell you about any change in circumstances that may affect my Council Tax.

Signature ________ Name (print) ______ Date __//__

Please provide your email address or telephone number in case we need to contact you about your application. You do not have to tell us but it will help us to contact you if we have any questions.

email address: ______________ Telephone: _______

If someone else has signed the form on your behalf please give the following details:

Name of the person who completed the form ______________

Their relationship to you (for example parent, friend)

You should now return this form to the council. We will then send the form to your doctor for completion of Part 4.

Part 4 To be completed by a registered medical practitioner

Notes - Council Tax legislation requires that a certificate has to be completed by a registered medical practitioner to confirm the severe mental impairment. Regulation 21 of the National Health Service (General Medical Services Contracts) (Scotland) Regulations 2004 requires certain certificates to be provided free of charge to a patient or their representatives – under Schedule 3 this includes a certificate to support a claim by or on behalf of a severely mentally impaired person to claim a discount or exemption from liability to pay the Council Tax.

Paragraph 2(1) Schedule 1 of the Local Government Finance Act 1992 defines severe mental impairment as someone who is suffering from a severe mental impairment of intelligence and social functioning, (however caused), which appears to be permanent.

Declaration by a registered medical practitioner - I certify that in my opinion that the applicant named in Part 1 of this form is suffering from a severe mental impairment of intelligence and social functioning, (however caused), which appears to be permanent.

Date from which the person named in Part 1 was first diagnosed __//___

Signature __________ Date // Telephone: _______

Name _________________

Address of surgery _____________

______ Postcode_______

How information about you will be used - we need the information on this form to determine if you are entitled to a Council Tax or Scottish Water (water and waste water) discount/exemption and to process your application. The Local Government Finance Act 1992 is the legal basis for the Council processing your personal information.

  • The information may be shared within the local authority, with other local authorities and Audit Scotland to detect and prevent fraud. Any medical information that you have supplied to support this application is “special category” personal data and will only be disclosed to third parties as necessary for the operation and administration of Council Tax.

For more information about how we process information, how long we retain the information, or the right to complain please contact us or visit http://www.orkney.gov.uk/Online-Services/privacy.htm. If you are unable to access the Council’s website you can request a paper copy from the Council.

Pease return the completed form to the Council Tax Section, Orkney Islands Council, Council Offices, Kirkwall, Orkney, KW15 1NY. Tel: (01856) 873535 Ext 2133

email: revenues@orkney.gov.uk website: http://www.orkney.gov.uk/ May 2018

For official use only:

Ctax Ref ____ Issued // Input by ___ Date// Contact Details Y / N