Application for a discretionary housing payment

If you wish to be considered for a discretionary housing payment, please complete the following form.

Personal details

Full name

Full address (including post code)

Contact number

Email address

Claim reference

Claim details

I wish to apply for a discretionary housing payment for the following reason(s).

Who do you currently live with?

Please complete the following questions so we can assess your entitlement to these payments.

When did you move to this address?

If you moved in the past 12 months please state your previous address.

Were you able to afford the rent/Council Tax when you moved in?

If you could not afford the rent why did you take the tenancy on?

If yes, please tell us how you were able to afford it (e.g. in work)?

Have you asked the landlord to reduce the rent?

What was the outcome?

Have you tried to find cheaper accommodation?

Is there a reason why you could not move if you found cheaper accommodation?

Please confirm authorisation for us to contact your landlord directly.

How much notice do you have to give?

When does your current tenancy end?

Do you have relatives or friends who could help?

Could relatives or friends provide you with accommodation, if only temporarily?

Could relatives or friends, or anyone who lives with you help with the rent or Council Tax?

Please confirm the amount of any rent arrears you have.

Please explain what action your landlord has taken against you because of your rent arrears? For example have you received a notice seeking possession and if so when?

Do you or any of your family have any disabilities or health problems?

If you have answered "Yes" to the previous question, please provide details.

Have you recently been bereaved?

If you have answered "Yes" to the previous question, please provide details.

Do you have rent and/or Council Tax arrears?

Do you have any other debts e.g. HP, loans, fines.

If you have answered "Yes" to the previous question, please provide details.

Do you have any savings or property (including holiday homes or timeshares) in this country or abroad?

Do you have any policies or other long-term investment, which will mature in the future? If so please give details of the policy and maturity date.

Is there anything else that you think we should know in support of your application?

Household income

Please now complete your household income details.

Take home pay

Partner's take home pay (if relevant)

Job Seeker's Allowance

Income support

Employment and Support Allowance

Incapacity benefit

Working tax credit

Child tax credit

Child benefit

Maintenance

State pension

Private pension

Any other income (please specify)

Household expenses

Please now complete your expenses details. If any of your expenses are unusually high, please state why.

Please now complete your household expense details. If any of your expenses are unusually high, please state why.

Mortgage

Rent

Ground rent

Buildings insurance

Contents insurance

Council tax

Water rates

Gas

Electricity

Life insurance

Child maintenance

Food/ housekeeping

Clothing

Tobacco/ cigarettes

TV license/ TV rental

Cable/ satellite

Telephone/ mobile phone

Car loan

Other loan repayments

Car tax

Car insurance

Petrol/ diesel

Other travel expenses

Any other expenses

Declaration - please read carefully.

Declaration text

The Council can prosecute anybody who gives false information or documents about their claim for a Discretionary Housing Payment, or anybody who keeps claiming after their circumstances have changed in a way that would affect whether they would receive a Discretionary Housing Payment.

This is my claim for a Discretionary Housing Payment.
I will tell you if the information on any letter you send me is incorrect.
The information I have given is true and complete.
You can check any information relevant to my application. This includes sending a Certificate of earnings direct to my employer if required.
I am not claiming a Discretionary Housing Payment for any other address.
I understand that you may contact the Home Office, Benefits Agency or Employment Service to check the information I have given on the form and to get other information.
I will write to you straight away if there are any changes in my circumstances so that you can work out my Discretionary Housing Payment again. If I do not, and get too large an award, an award the Council can ask me to pay it back. I may also be prosecuted under the Social Security Administration (Fraud) Act 1997.

I have read and understood the above declaration.

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