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 shows the Orkney Islands Council application form title, office-use fields, introductory instructions, and the opening questions in Part 1, with separate fields for the applicant 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.

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

You	Your partner
Surname or family name	Surname or family name
Other names	Other names
Title (Mr, Mrs, Ms, Other)	Title (Mr, Mrs, Ms, Other)
Tell us any other names you have used	Tell us any other names they have used
Address you are claiming for	Address you are claiming for
Do not tell us your partner's address if it is the same as yours.
Date of birth	Date of birth
National Insurance number	National Insurance number
Your home telephone number	Your partner's home telephone number
Your mobile phone number	Your partner's mobile phone number
Your email address	Your partner's email address

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	Your partner
Address	Address
Postcode	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:

IMAGE: The second page continues Part 1 with questions for the applicant and partner about previous claims, residence, hospital stays, disability benefits, mobility schemes, carers, and absence from home.

Question	You	Your partner
Have you or your partner claimed Housing Benefit or Council Tax Reduction in the last 12 months?	No / Yes	No / Yes
If Yes, what address did you claim for?	Address and postcode	Address and 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?	No / Yes. If Yes, what is your nationality? We will write to you for further details.	No / Yes. If Yes, what is your nationality? We will write to you for further details.
Are you or your partner in hospital at the moment?	No / Yes. When did you go in? When do you expect to come out?	No / Yes. 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?	No / Yes. If Yes, we need to see proof.	No / Yes. If Yes, we need to see proof.
Do you or your partner have a vehicle from a Mobility Scheme?	No / Yes	No / Yes
Does anyone get Carer's Allowance for looking after you or your partner?	No / Yes. If Yes, we need to see proof.	No / Yes. 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?	No / Yes. If Yes, we will write to you.	No / Yes. 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.)	No / Yes. If Yes, we need to see proof.	No / Yes. If Yes, we need to see proof.
Are you or your partner living away from home at the moment?	No / Yes. When did you last live at home? When do you expect to go home? The reason for the absence.	No / Yes. 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.

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.

First child	Second child	Third child	Fourth child
Surname or family name	Surname or family name	Surname or family name	Surname or family name
Other names	Other names	Other names	Other names
Date of birth	Date of birth	Date of birth	Date of birth
What is the child's sex?	What is the child's sex?	What is the child's sex?	What is the child's sex?
Child's relationship to you	Child's relationship to you	Child's relationship to you	Child's relationship to you
Child's relationship to your partner?	Child's relationship to your partner?	Child's relationship to your partner?	Child's relationship to your partner?
Usual address if different from yours	Usual address if different from yours	Usual address if different from yours	Usual address if different from yours
Who gets Child Benefit for them? (We need to see proof.)	Who gets Child Benefit for them? (We need to see proof.)	Who gets Child Benefit for them? (We need to see proof.)	Who gets Child Benefit for them? (We need to see proof.)
Is the child registered blind or getting Disability Living Allowance or Personal Independence Payment? No / Yes. (If Yes, we need to see proof.)	Is the child registered blind or getting Disability Living Allowance or Personal Independence Payment? No / Yes. (If Yes, we need to see proof.)	Is the child registered blind or getting Disability Living Allowance or Personal Independence Payment? No / Yes. (If Yes, we need to see proof.)	Is the child registered blind or getting Disability Living Allowance or Personal Independence Payment? No / Yes. (If Yes, we need to see proof.)
Do you pay a registered childminder, nursery or after-school club any childminding costs for this child? No / Yes	Do you pay a registered childminder, nursery or after-school club any childminding costs for this child? No / Yes	Do you pay a registered childminder, nursery or after-school club any childminding costs for this child? No / Yes	Do you pay a registered childminder, nursery or after-school club any childminding costs for this child? No / Yes
If Yes, tell us the name of the childminder.	If Yes, tell us the name of the childminder.	If Yes, tell us the name of the childminder.	If Yes, tell us the name of the childminder.
How much do you pay each week? £ (We need to see proof.)	How much do you pay each week? £ (We need to see proof.)	How much do you pay each week? £ (We need to see proof.)	How much do you pay each week? £ (We need to see proof.)

IMAGE: The third page presents Part 2 as a four-column child information table, with fields for names, dates of birth, relationships, Child Benefit, disability status, childcare provider, and weekly childcare costs.

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.

First person	Second person	Third person
Surname or family name	Surname or family name	Surname or family name
Other names	Other names	Other names
Date of birth	Date of birth	Date of birth
Their relationship to you or your partner	Their relationship to you or your partner	Their relationship to you or your partner
Do they get Income Support, Income-based Jobseeker's Allowance, Income Related Employment & Support Allowance, Pension Credit? No / Yes. (If Yes, we need to see proof.)	Do they get Income Support, Income-based Jobseeker's Allowance, Income Related Employment & Support Allowance, Pension Credit? No / Yes. (If Yes, we need to see proof.)	Do they get Income Support, Income-based Jobseeker's Allowance, Income Related Employment & Support Allowance, Pension Credit? No / Yes. (If Yes, we need to see proof.)
Do they get Universal Credit? No / Yes. (If Yes, we need to see proof.)	Do they get Universal Credit? No / Yes. (If Yes, we need to see proof.)	Do they get Universal Credit? No / Yes. (If Yes, we need to see proof.)
Do they get Disability Living Allowance, Personal Independence Payment, Attendance Allowance, or are they registered blind? No / Yes. (If Yes, we need to see proof.)	Do they get Disability Living Allowance, Personal Independence Payment, Attendance Allowance, or are they registered blind? No / Yes. (If Yes, we need to see proof.)	Do they get Disability Living Allowance, Personal Independence Payment, Attendance Allowance, or are they registered blind? No / Yes. (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? No / Yes. If Yes, tell us which.	Are they a full-time student, a student nurse, a care worker, an apprentice or on youth training? No / Yes. If Yes, tell us which.	Are they a full-time student, a student nurse, a care worker, an apprentice or on youth training? No / Yes. If Yes, tell us which.
Do they pay rent or money for board and lodgings to you or your partner? No / Yes. How much? £ a week. (If Yes, we need to see proof.)	Do they pay rent or money for board and lodgings to you or your partner? No / Yes. How much? £ a week. (If Yes, we need to see proof.)	Do they pay rent or money for board and lodgings to you or your partner? No / Yes. How much? £ a week. (If Yes, we need to see proof.)
Are they severely mentally impaired? No / Yes	Are they severely mentally impaired? No / Yes	Are they severely mentally impaired? No / Yes

IMAGE: The fourth page shows the first part of Part 3 with three columns for other household members and questions about benefits, education, rent, board, and severe mental impairment.

Part 3 About other people who live with you - continued

Question	First person	Second person	Third person
Are they in legal custody at the moment?	No / Yes. When are they expected to come out?	No / Yes. When are they expected to come out?	No / Yes. When are they expected to come out?
Are they in hospital at the moment?	No / Yes. When did they go in? When are they expected to come out?	No / Yes. When did they go in? When are they expected to come out?	No / Yes. When did they go in? When are they expected to come out?
Do they normally work for 16 hours or more a week?	No / Yes. Tell us their earnings before deductions for things like tax and National Insurance. £. We need to see proof of their earnings.	No / Yes. Tell us their earnings before deductions for things like tax and National Insurance. £. We need to see proof of their earnings.	No / 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.	No / Yes. Tell us their other income before deductions for things like tax and National Insurance.	No / Yes. Tell us their other income before deductions for things like tax and National Insurance.	No / Yes. Tell us their other income before deductions for things like tax and National Insurance.

For each person, provide:

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, other income, and relationships between household members.

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?

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.

You	Your partner
What kind of work do you do?	What kind of work do you do?
When did the business start?	When did the business start?

IMAGE: The sixth page shows Parts 4 to 6, including housing tenure, rent to Orkney Islands Council, benefits claims, and self-employment details.

Part 6 About being self employed - continued

Question	You	Your partner
What is the business address?	Address and postcode	Address and postcode
Are there any other partners in the business?	No / Yes. Tell us their name and address.	No / Yes. Tell us their name and address.
How many hours a week do you usually work?	Hours	Hours
Do you pay into a private pension scheme?	No / Yes. How much? £. How often? Every. We need to see proof.	No / Yes. How much? £. How often? Every. 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.

You	Your partner
What kind of work do you do?	What kind of work do you do?
What is your employer's name and address?	What is your employer's name and address?
Postcode	Postcode
When did you start this job?	When did you start this job?
What is your payroll number?	What is your payroll number?

IMAGE: The seventh page continues self-employment questions and begins Part 7 with employer details, multiple employment, work type, employer address, start date, and payroll number.

Part 7 About working for an employer - continued

Question	You	Your partner
Are you employed for a limited period?	No / Yes. When will you finish?	No / Yes. When will they finish?
How often do you get paid?	Every	Every
How much do you get paid before tax and National Insurance are taken off?	£	£
Give details of any regular overtime, bonuses or commission.	£	£
When was your last pay rise?	Date	Date
How many hours a week do you usually work?	Hours	Hours

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?

You: No / Yes
Your partner: No / Yes

Do you pay into a private pension scheme?

You: No / Yes. How much? £. How often? Every. We need to see proof.
Your partner: No / Yes. How much? £. How often? Every. 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 pay, hours, payment methods, statutory payments, and private pension contributions for the applicant and partner.

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.

Question	You	Your partner
What other work do you do?
What is the name and address of the person or organisation you do this work for?	Address and postcode	Address and postcode
When did you start this work?	Date	Date
How many hours a week do you usually work?	Hours	Hours
Do you get paid?	No / Yes. How much? £. We need to see proof.	No / Yes. How much? £. We need to see proof.
How often do you get paid?	Every	Every

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 shows Part 8 with fields for other paid or voluntary work, the organisation involved, dates, hours, earnings, 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.

You	Your partner
The name of the benefit	The name of the benefit
Amount of benefit £	Amount of benefit £
How often is it paid? Every	How often is it paid? Every
Method of payment	Method of payment
The name of the benefit	The name of the benefit
Amount of benefit £	Amount of benefit £
How often is it paid? Every	How often is it paid? Every
Method of payment	Method of payment
The name of the benefit	The name of the benefit
Amount of benefit £	Amount of benefit £
How often is it paid? Every	How often is it paid? Every
Method of payment	Method of payment
The name of the benefit	The name of the benefit
Amount of benefit £	Amount of benefit £
How often is it paid? Every	How often is it paid? Every
Method of payment	Method of payment

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 and provides four repeated benefit-entry sections for the applicant 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?

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

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

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 shows Part 10 with three sections for other income and a final question about money owed to the applicant, partner, or children.

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.

Account	Details
Name of Bank or Building Society	Account number
Whose name is the account in?	How much is in the account?
Name of Bank or Building Society	Account number
Whose name is the account in?	How much is in the account?
Name of Bank or Building Society	Account number
Whose name is the account in?	How much is in the account?
Name of Bank or Building Society	Account number
Whose name is the account in?	How much is in the account?

Do you or your partner have any premium bonds?

No
Yes — Value £

Do you or your partner have any National Savings Certificates?

For each certificate provide:

Issue number
Value £
How many?

IMAGE: The twelfth page shows Part 11 with four bank-account sections and fields for Premium Bonds and National Savings Certificates.

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

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

Provide:

Company name
How many?

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 questions about investments, property, savings, trusts, and house-sale proceeds, followed by the large free-text box for Part 12.

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 begins the checklist with evidence requirements for identity, National Insurance numbers, and self-employed earnings.

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.

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: The fifteenth page continues the evidence checklist and contains the privacy notice explaining how application information may be processed and shared, together with a QR code linking to the Orkney Council privacy information page.

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

Our services

What's on

About Us

Application for Housing Benefit and / or Council Tax Reduction

Part 1 About you and your partner

Part 2 About children

Part 3 About other people who live with you

Part 3 About other people who live with you - continued

Part 4 About where you live

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

Part 6 About being self employed

Part 6 About being self employed - continued

Part 7 About working for an employer

Part 7 About working for an employer - continued

Part 8 About any other work

Part 9 About benefits, pensions and tax credits

Part 10 About other money coming in

Other money 1

Other money 2

Other money 3

Part 11 About bank accounts, savings, investments and property

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

Part 12 Anything else you need to tell us

Part 13 Backdating

Part 14 Checklist

Evidence of identity - only for new claims

Evidence of National Insurance number

Evidence of self-employed earnings

Part 14 Checklist - continued

Evidence of earnings

Evidence of other income

Evidence of benefits, pensions and tax credits

Evidence of bank accounts, savings, investments and property

Evidence of money paid out

Part 15 How information about you will be used

Part 16 Declaration

Part 17 What to do next