Application for Housing Benefit and / or Council Tax Reduction

By completing this form you are applying for assistance with your rent and/or your Council Tax based on the financial circumstances of you and your household. You should return the form to the Council as soon as possible to avoid losing benefit. If you don't have everything that we ask for, you can provide any missing information or evidence later.

Please read the accompanying guidance notes on applying before you fill in the form.

If you are only claiming Second Adult Rebate, complete parts 1, 3 and 16 of this form and tick this box.

IMAGE: The first page displays the Orkney Islands Council logo, the title “Application for Housing Benefit and / or Council Tax Reduction”, an office-use box, introductory instructions, and blank fields and checkboxes for the claimant and partner.

Part 1 About you and your partner

Do you have a partner who normally lives with you?

By Partner, we mean someone you are married to, or in a civil partnership or living together as though you are married or in a civil partnership.

• No
• Yes

If you have a partner, you must answer all the questions about them, as well as yourself.

You

• Surname or family name
• Other names
• Title (Mr, Mrs, Ms, Other)
• Tell us any other names you have used
• Address you are claiming for
• Postcode
• Date of birth
• National Insurance number
• Your home telephone number
• Your mobile phone number
• Your email address

Your partner

• Surname or family name
• Other names
• Title (Mr, Mrs, Ms, Other)
• Tell us any other names they have used
• Address you are claiming for
• Postcode
• Date of birth
• National Insurance number
• Home telephone number
• Mobile phone number
• Email address

Do not tell us your partner's address if it is the same as yours.

We need to see proof of your identity and National Insurance Number. See the checklist - Part 14.

If you have moved home in the last 12 months, tell us your last address.

• You: Last address; Postcode
• Your partner: Last address; Postcode

Were you a home owner, a private or council tenant or a boarder at this address?

Were they a home owner, a private or council tenant or a boarder at this address?

For office use only

• Date of Issue:
• Claim Reference:

Have you or your partner claimed Housing Benefit or Council Tax Reduction in the last 12 months?

If Yes, what address did you claim for?

• You: Address; Postcode
• Your partner: Address; Postcode

Have you or your partner come to live in Scotland, England, Northern Ireland, Wales, the Republic of Ireland, the Channel Islands or the Isle of Man in the last 2 years?

If Yes, what is your nationality? We will write to you for further details.

Are you or your partner in hospital at the moment?

• If you are in hospital: When did you go in? When do you expect to come out?
• If your partner is in hospital: When did they go in? When do they expect to come out?

Do you or your partner get Attendance Allowance, Disability Allowance or Personal Independence Payment?

If Yes, we need to see proof.

Do you or your partner have a vehicle from a Mobility Scheme?

Does anyone get Carer's Allowance for looking after you or your partner?

If Yes, we need to see proof.

Do you or your partner have a carer who lives somewhere else, but provides care overnight in your home?

If Yes, we will write to you.

Have you ever been told you were entitled to Carer's Allowance? (Tick 'Yes' even if you were not paid any benefit.)

If Yes, we need to see proof.

Are you or your partner living away from home at the moment?

If Yes:

• You: When did you last live at home? When do you expect to go home? The reason for the absence.
• Your partner: When did they last live at home? When do you expect them to return? The reason for the absence.

Please tick if either you or your partner are:

• a student
• on youth training
• an apprentice
• registered blind
• in legal custody
• long term sick or disabled
• severely mentally impaired

We will contact you if we need any more information.

IMAGE: The second page continues Part 1 with questions about previous claims, residence in the United Kingdom or nearby jurisdictions, hospital stays, disability and care-related benefits, Mobility Scheme vehicles, carers, and periods away from home. It contains paired No and Yes checkboxes for you and your partner.

Part 2 About children

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 or over but still under 20 and in education doing a course not higher than GCE A-level, or SCE Higher level or GNVQ (advanced) or doing approved training.

Are there any children in your household?

• No — Go to Part 3.
• Yes.

If there are more than 4 children, use a separate piece of paper to tell us the information we ask for on this page.

If you are sending a separate piece of paper, tick this box.

IMAGE: The third page presents Part 2 as a four-column child-information form, with fields for each child’s identity, date of birth, sex, relationships, address, Child Benefit recipient, disability status, childcare costs, childminder and weekly payment.

Part 3 About other people who live with you

Tell us about all the people who usually live with you and your partner.

Do any adults normally live with you and your partner?

By adults we mean people over 16 who nobody gets Child Benefit for.

• No — Go to Part 4.
• Yes.

Now tell us about all the people who normally live with you and your partner.

If you want to tell us about more than 3 people, use a separate piece of paper.

If you are sending a separate piece of paper, tick this box.

For example, aunt, brother, daughter, father, grandson, grandmother, stepdaughter, joint-tenant, joint owner, sub-tenant, lodger, boarder or friend.

Do they get Income Support, Income-based Jobseeker's Allowance, Income Related Employment & Support Allowance, Pension Credit? (If Yes, we need to see proof)

Do they get Universal Credit? (If Yes, we need to see proof)

Do they get Disability Living Allowance, Personal Independence Payment, Attendance Allowance, or are they registered blind? (If Yes, we need to see proof)

Are they a full-time student, a student nurse, a care worker, an apprentice or on youth training?

If Yes, tell us which.

Do they pay rent or money for board and lodgings to you or your partner? (If Yes, we need to see proof)

Are they severely mentally impaired?

IMAGE: The fourth page presents Part 3 with three columns for other adults living in the household. It includes identity fields, relationship examples, questions about benefits, Universal Credit, disability, education or training, rent or board payments, and severe mental impairment.

Part 3 About other people who live with you - continued

Are they in legal custody at the moment?

Are they in hospital at the moment?

Do they normally work for 16 hours or more a week?

If Yes, tell us their earnings before deductions for things like tax and National Insurance.

We need to see proof of their earnings.

Do they have any other income at all?

Make sure you tell us about all other income they have. This includes any benefits or Allowances or interest from savings and investments.

If Yes, we need to see proof.

For each person:

• What type of income?
• How much before deductions? £
• What type of income?
• How much before deductions? £
• What type of income?
• How much before deductions? £

Are any of the people who normally live with you married to each other, civil partners or living together as if they are married or civil partners?

• No
• Yes — Tell us their names: ____ is the partner of ____

IMAGE: The fifth page continues Part 3 with questions about legal custody, hospital stays, employment, earnings, other income and relationships between adults in the household. It provides separate fields for the first, second and third person.

Part 4 About where you live

Tell us who owns your home.

When did you move to this address?

If you have not moved in yet, tell us when you expect to move in and confirm this in writing after you actually move in.

Do you rent your home?

• No — Go to Part 5.
• Yes — Answer the question below.

Do you pay rent to Orkney Islands Council?

• No — Complete form Additional information about your rent, then go to Part 5. (If you do not have this form please contact the Council.)
• Yes — Answer the next question.

Are you a joint tenant?

• No — If, No, proceed to Part 5.
• Yes — If, Yes, please tell us your joint tenant's name(s) then proceed to Part 5.

Part 5 About Income Support, Jobseeker's Allowance, Employment and Support Allowance, Pension Credit or Universal Credit

Are you or your partner getting Income Support, Income-Based Jobseekers Allowance, Income-Related Employment and Support Allowance, Guaranteed Pension Credit or Universal Credit?

• No
• Yes — Go to Part 12.

Are you or your partner waiting to hear about a claim for Income Support, Jobseeker's Allowance, Employment and Support Allowance, Pension Credit or Universal Credit?

• No
• Yes

If Yes, when did you claim?

Tell us what you have claimed.

Part 6 About being self employed

Are you or your partner self-employed?

• No — Go to Part 7.
• Yes — Answer the questions in this part.

You must send us your trading accounts for the last financial year. If you have only recently set up the business, or do not have a full year's accounts, we will need to see some other proof of your income. We will write to you about this.

IMAGE: The sixth page contains Parts 4, 5 and 6, with questions about home ownership, rent, joint tenancy, benefit claims and self-employment. It includes blank fields for the claimant’s and partner’s work and business start date.

Part 6 About being self employed - continued

We need to see proof.

Part 7 About working for an employer

Do you or your partner work for an employer?

• No — Go to Part 8.
• Yes — Answer the questions in this part.

Do you or your partner work for more than one employer?

• No
• Yes — Tell us about the other employers on a separate piece of paper and send it with this form.

If you are sending a separate piece of paper, please tick box.

IMAGE: The seventh page continues the self-employment section with business-address, business-partner, working-hours and private-pension fields, then begins Part 7 with employer, job, employer-address, start-date and payroll-number fields.

Part 7 About working for an employer - continued

How do you get paid?

• In cash
• By cheque
• Into a bank/building society

Are you getting Statutory Sick Pay, Statutory Maternity Pay or Statutory Paternity Pay at the moment?

Do you pay into a private pension scheme?

We need to see proof.

We must see proof of earnings before we can decide how much benefit you can get. Read the checklist at Part 14 to see what you can use as evidence.

IMAGE: The eighth page continues Part 7 with employment duration, pay frequency and amounts, overtime, pay rises, working hours, payment method, statutory payments and private pension contributions. A notice at the bottom states that proof of earnings is required.

Part 8 About any other work

Do you or your partner do any other work at all?

This could be voluntary work or any other work, even if it is not paid work.

• No — Go to Part 9.
• Yes — Answer the questions in this part.

We need to see proof.

We must see proof of any earnings before we can decide how much benefit you can get. Read the checklist at Part 14 to see what you can use as evidence.

IMAGE: The ninth page presents Part 8 with parallel fields for the claimant and partner about unpaid or paid additional work, the organisation or person involved, start date, hours, amount paid and payment frequency.

Part 9 About benefits, pensions and tax credits

Are you or your partner getting any benefits, pensions or tax credits or waiting to hear about any you have claimed?

• No — Go to Part 10.
• Yes — Tell us about the benefits below.

For example, read the list below and tell us about any that you or your partner are getting or have claimed.

• Armed Forces Independence Payment
• Attendance Allowance
• Bereavement Allowance
• Carer's Allowance
• Child Benefit
• Children's Tax Credit
• Disability Living Allowance
• Guardian's Allowance
• Employment and Support Allowance
• Fostering Allowance
• Industrial Injuries Disablement Benefit
• Industrial Death Benefit
• Contribution-based Jobseeker's Allowance
• Maternity Allowance / Paternity Pay
• Personal Independence Payment
• Sick Pay
• State Retirement Pension
• Severe Disablement Allowance
• Universal Credit
• War Disablement Benefit, War Pension or War Widow's Pension
• Widow's or Widower's Benefits
• Working Tax Credit
• Any other Department for Work and Pensions / social security benefits

If there are more than 4 benefits, tell us about the others on a separate piece of paper and send it with this form.

If you are sending a separate piece of paper, tick this box.

We must see proof of any benefits coming in before we can decide how much benefit you can get. Read the checklist at Part 14 to see what you can use as evidence.

IMAGE: The tenth page lists benefits, pensions and tax credits that may need to be declared, and provides four repeated benefit-record sections for the claimant and partner.

Part 10 About other money coming in

Do you, your partner, or any children you are claiming for, have any money coming in (or expect to have some money coming in) that you have not told us about on this form?

• No — Go to Part 11.
• Yes — Answer the questions in this part.

This includes occupational pensions, maintenance or child support, annuities, student loans/grants, money from a trust fund, charitable/voluntary payments or health insurance.

Other money 1

• What is the money for?
• Who gets it?
• How much do they get? £
• How often? Every
• When did they start getting it?

Other money 2

• What is the money for?
• Who gets it?
• How much do they get? £
• How often? Every
• When did they start getting it?

Other money 3

• What is the money for?
• Who gets it?
• How much do they get? £
• How often? Every
• When did they start getting it?

Does anyone owe money to you, your partner, or to any children you are claiming for?

• No
• Yes — If Yes, to whom and what for?
• How much? £

We must see proof of any money coming in before we can decide how much benefit you can get. Read the checklist at Part 14 to see what you can use as evidence.

IMAGE: The eleventh page contains Part 10 with three sections for other money coming in, including its purpose, recipient, amount, frequency and start date, followed by a question about money owed to the household.

Part 11 About bank accounts, savings, investments and property

This includes cash, current accounts and savings accounts with a bank or building society, Post Office accounts, Premium Bonds, National Savings Certificates and stocks and shares.

Do you or your partner have any bank, building society or post office accounts?

• No
• Yes — Tell us about these accounts. If there are more than 4 accounts, tell us about the others on a separate piece of paper and send with this form.

If you are sending a separate piece of paper, tick this box.

Do you or your partner have any premium bonds?

• No
• Yes — Value £

Do you or your partner have any National Savings Certificates?

• No
• Yes

IMAGE: The twelfth page presents Part 11 with fields for four bank, building society or post office accounts, followed by questions about Premium Bonds and National Savings Certificates, including issue number, value and quantity.

Part 11 About bank accounts, savings, investments and property - continued

Do you or your partner have any stocks, shares, bonds or unit trusts?

• No
• Yes

Do you or your partner own or partly own any land or property other than the home you live in, in either the UK or abroad?

• No
• Yes

Tick Yes, even if you have a mortgage or loan for the property. Please write the address in the box below - we will write to you.

Do you or your partner have any other savings, capital or investments?

This includes cash, ISAs, Income Bonds, compensation or any other money you haven't told us about on the form?

• No
• Yes — Tell us about this.

Do any children you are claiming for own any land or property or have any money or property held in trust?

• No
• Yes — Tell us about this.

Do any of your savings or investments include money from the sale of a house?

• No
• Yes — Tell us about this.

We must see proof of savings, capital and investments before we can decide how much benefit you can get. Bank statements or passbooks must show the last two months transactions. Other items of proof may include certificates for premium bonds and stocks and shares. We must see original documents, not copies.

Part 12 Anything else you need to tell us

Use this box to tell us anything else you think we should know about. Use a separate sheet and attach it to this form if you need to.

If you are sending a separate piece of paper, tick this box.

IMAGE: The thirteenth page continues Part 11 with fields for stocks, shares, bonds, unit trusts, additional property, other savings or investments, children’s property or trusts, and money from the sale of a house. It then begins Part 12 with a large blank box for additional information.

Part 13 Backdating

We usually award benefit from the Monday after the day we receive your claim. We may be able to pay benefit from an earlier date if you have a good reason for not claiming earlier. If you want us to consider paying your benefit from an earlier date, tell us when you want benefit from and why you did not claim earlier. We will not backdate your benefit unless you have a good reason for not claiming earlier, and that good reason exists for all of the period.

You must provide evidence of the reason, for example, letters from your doctor or social worker.

Please note that we cannot backdate for any period more than 1 month for working age customers and 3 months for pension age customers. Failure to make enquiries earlier and ignorance of the benefit scheme are not considered good reason for not claiming earlier.

If you want us to start paying your benefit from an earlier date, tell us when you want to claim from.

Were your circumstances the same as they are on this form?

• No — If no, provide details below and proof of income and savings.
• Yes

Provide the reasons you did not claim sooner. These reasons must have been continuous throughout the period of the backdate request.

Part 14 Checklist

Please tick to tell us what proof you are sending with this form. We must see original documents, not copies. Please do not send valuable items through the post. If you can, bring them into our office we will take the details we need and give you the documents back straightaway. If you cannot get into the office, please phone us for more advice.

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

If you cannot send the proof we need at the moment, send the form back to us now and send the proof later. We can start to process your claim, but we will not be able to pay you any benefit until we have all the proof.

Evidence of identity - only for new claims

Such as birth certificate, marriage certificate, passport, National Insurance number card, medical card, driving licence, UK residence permit, EEC identity card or recent electricity bill. We may need to see several of these documents for each person (provide one item if photographic id and 2 if not).

Evidence of National Insurance number

Such as a National Insurance number card, payslips or letter from social security or the tax office.

Evidence of self-employed earnings

If you or your partner are self-employed, we need to see your accounts for the last financial year or if you have been trading for less than 6 months, a summary of your trading records so far. If you do not have up-to-date accounts, you should complete a Self-Employed earnings form.

IMAGE: The fourteenth page contains Part 13’s backdating questions and Part 14’s introductory checklist guidance. It lists evidence of identity, National Insurance number and self-employed earnings, with checkboxes alongside the evidence categories.

Part 14 Checklist - continued

Evidence of earnings

This means your last 5 payslips if you are paid every week, your last 3 payslips if you are paid every 2 weeks or your last 2 payslips if you are paid every month. If you do not have your payslips, you can ask your employer to complete an Earnings Enquiry form.

Evidence of other income

Such as pension slips from a former employer, a letter from an insurance company showing the payments you get or a letter from the CSA or your former partner showing how much child support you are getting.

Evidence of benefits, pensions and tax credits

Such as current award notices or letters from the Department of Work and Pensions or Her Majesty's Revenue and Customs confirming how much you get. If you do not have proof, please let us know straight away.

Evidence of bank accounts, savings, investments and property

Such as all your bank, building society or post office books, full bank statements. These must show details of any transactions for at least the last two months.

Evidence of money paid out

If you pay for registered child care, you should enclose receipts for the payments you make.

IMAGE: The fifteenth page continues the checklist with evidence of earnings, other income, benefits, pensions and tax credits, bank accounts, savings, investments and property, and money paid out. It also contains Part 15 and a QR code beneath the privacy-information web address.

Part 15 How information about you will be used

We need the information on this form in order to determine if you are entitled to Housing Benefit and/or Council Tax Reduction and to process your application.

The Security Administration Act 1992, The Welfare Reform Act 2012 and the Local Government Finance Act 1992 is the legal basis for processing your personal information.

The information may be shared as follows:

• Within the local authority, with other local authorities, Audit Scotland, the Department for Work and Pensions, the Scottish Government and Her Majesty’s Revenues and Customs to detect, investigate and prevent fraud.
• With the Department for Work and Pensions and Her Majesty’s Revenues and Customs, to verify and check accuracy of information provided, amending or supplementing such information.
• With the Department for Work and Pensions, Her Majesty’s Revenues and Customs and debt collection partners, to pursue outstanding Housing Benefit overpayments.
• Within the local authority to help improve the services provided by the Council, such as information relating to other Council Tax discounts/exemptions.

Any medical information that you provide to support any application for discount/exemption is treated as special category personal data and will only be disclosed to third parties as necessary for the operation and administration of Housing Benefit and /or Council Tax Reduction.

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. Users of smartphones can also scan the code below to access the information.

IMAGE: A QR code is provided so smartphone users can access the Council’s privacy information online at the privacy-information web address given above.

Part 16 Declaration

Even if someone else has filled in this form for you, you must sign this declaration if you can. 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 prosecution.

I know I must let the Benefits Section of Orkney Islands Council know about any changes in my circumstances which might affect my claim. This could be things like where I live, changes in my income or savings, who lives with me, changes in the income of anyone who lives with me, changes to my benefits, if I or my partner go into hospital or the amount that I pay for my rent.

I declare the information I have given on this form is correct and complete.

• Signature of person claiming
• Date

If this form has been filled in by someone other than the person claiming:

• Name of the person who filled in the form
• Tell us why are you are filling this form in for someone else?
• I declare, as far as possible, I have confirmed with the person that the answers I have written on this form are correct.
• Signature of the person
• Relationship to the person claiming
• Date

Part 17 What to do next

You should now:

• have filled in the claim form
• collected any evidence to support your claim
• return the form to the following address:

Benefits Section, Orkney Islands Council
Council Offices, Kirkwall, KW15 1NY.

If you have told us that you are going to send us more information at a later date, send it to the address above.

If you have any queries you can contact us by telephone on (01856) 886312 or (01856) 873535 Extn 2116 or by email at benefits@orkney.gov.uk.

For more information visit our website:

http://www.orkney.gov.uk/service-directory/h/housing-benefit.htm

The information on this form may also be used to assess possible entitlement to Council Tax Discount.

Doc revised June 2018

For office use only

IMAGE: The final page contains Part 16’s declaration and signature fields, followed by Part 17’s checklist of next steps, the Benefits Section postal address, telephone numbers, email address, website address, the note about Council Tax Discount, the revision date “Doc revised June 2018”, and an office-use-only box.