Claim form for Discretionary Housing Payments
IMAGE: The Orkney Islands Council crest with the text “ORKNEY ISLANDS COUNCIL”.
Discretionary Housing Payments are intended to help anyone in need of further financial assistance to pay their rent.
The amount of money available to the Council to make these payments is strictly limited. This means that before we can consider your request we must have extra information about your circumstances. If you wish to apply, please complete the following questions.
If you rent your home from Orkney Islands Council or Orkney Housing Association Ltd and have more bedrooms that your household need you will be considered as under-occupying the property and your housing costs will be reduced.
Part 1 – About you and your home
| Name: | National Insurance No: | ||
| Address: | Date of Birth: | ||
| Telephone No: | |||
| Partner’s Name: | National Insurance No: | ||
| Email Address: | Date of Birth: |
| How many bedrooms are in your property? |
|---|
Tell us who lives in the property with you:
| Name: | Date of Birth: | Relationship to you: |
|---|---|---|
| How much is your rent? | (we need to see proof) |
| How much is your Universal Credit (Housing Element)? | (we need to see proof) |
| Landlords Name: | |
| Landlords Address: |
Part 2 – information to support your application (if not under occupying or restricted by the benefit cap)
Please describe any hardship or special circumstances, which you or the members of your family are suffering. Give the date that the hardship or special circumstances started and if appropriate a time when you feel this may change.
Please describe any health problems which you or the members of your family suffer from. Give the date the problem started and if appropriate a time when you feel this may change.
Please list all incomings and outgoings that you and your family have.
| Income per week £ | Expenditure per week £ |
|---|---|
How much can you afford to contribute towards your rent? Please explain why and tell us if and when you think this may change.
| Question | Yes | No |
|---|---|---|
| Have you tried to negotiate a lower rent with your landlord? | ||
| Are you in arrears with your rent? If yes, how much? |
Please tell us anything else you think we should know to support your application.
Part 3 - where should Discretionary Housing payments be paid to (if in receipt of Universal Credit Housing Costs)
| Name(s) of Account Holder(s): | |
| Branch Sort Code: | / / |
| Bank or Building Society Account Number: |
Part 4 - What happens next?
Provide the following information to support your application:
- Proof of your rent, this could be a rent letter or rent statement from your landlord;
- Proof of your Universal Credit award, this should be a copy of your statement from your journal which shows how your housing costs are worked out.
Part 5 - How information about you is used
The information on this form will be used to determine if you are entitled to Discretionary Housing Payments and 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.
For more information about how we process information, how long we retain the information, or the right to complain please contact us or visit www.orkney.gov.uk/online-services/privacy.htm.
Part 6 – Declaration
I declare that the information I have given on this form is correct and complete. I understand that if I give incorrect or incomplete information, I may be prosecuted.
I know that I must inform the Benefits Section immediately of any changes of circumstances and understand that failure to do so may result in recovery of any overpaid Discretionary Housing Payment.
I authorise Orkney Islands Council to verify any of the information given in this application form and to use the information provided on my application for Universal Credit and/or Council Tax Reduction to consider my application for Discretionary Housing Payment.
I understand that I must report in writing, within one calendar month of the date of the change, changes in my circumstances that may affect my application for a Discretionary Housing Payment.
| Your signature | Date |
|---|---|
If someone other than the person claiming filled in this form, please tell us why.
| Name of the person who filled in the form | |
| Tell us why you are filling this form in for someone else? |
I declare, as far as possible, I have confirmed that the answers I have written on this form are correct.
| Signature of the person | |
| Relationship to the person claiming |
Please return the completed form, along with any evidence, to: The Benefits Section, Chief Executive’s Service, Orkney Islands Council, School Place, Kirkwall, Orkney, KW15 1NY
Further Information
If you would like more information, please visit the Council’s website and search for Discretionary Housing Payments.
Contact the Council’s Benefits Section – Telephone: (01856) 873535 extension 2116
Email: benefits@orkney.gov.uk
Website: www.orkney.gov.uk