Cardiff County Council
A claim form for Housing Benefit/
Council Tax Benefit/Council Tax Reduction
Are you
(please tick one box):
a council tenant?
K an owner-occupier?
K
a private tenant?
K a housing association or social landlord tenant?
a hostel resident?
Did you claim at your last address? No Yes
Part 1
About you and your partner
Do you have a partner who
normally lives with you?
By partner we mean
• a person you are married to or a person
you live with as if you are married to
them, or
• a civil partner or a person you live with
as if you are civil partners
Last name
If you have a partner,
you must answer all
the questions about
them.
No
Yes
Other names
Date of birth
National Insurance number
You can find this on payslips or
letters from social security or the
tax office. We cannot decide your
claim if we do not have your
National Insurance number.
Tell us any other names you
have used.
Your phone number
You do not have to tell us this, but
it may help us deal with your claim
more quickly.
Title
(Mr, Mrs, Ms and so on)
Address
This is the address that you want to
claim benefit for.
Do not tell us your partner’s
address if it is the same as yours.
You
Your partner
Postcode:
Letters
Numbers
Letter
Postcode:
Letters
Numbers
Letter
/
/
What date did you move to this
address?
/
/
/
/
/
/
If you have moved home in the
last 12 months, tell us your last
address and the date you left the
property.
Have you or your partner come to
live in England, Northern Ireland,
Scotland, Wales, the Republic of
Ireland, the Channel Islands or the
Isle of Man in the last 5 years?
Postcode:
We will write to you about this.
We will write to you about this.
Postcode:
/
/
/
/
No
Yes
No
Yes
1
For official use
Date issued
Receipt Stamp
Part 1
About you and your partner -
continued
Have you or your partner
claimed Housing Benefit/
Council Tax Benefit/Council Tax
Reduction within the last 5
years?
When did you claim?
What address did you claim for?
What address did you claim for?
No
Yes
When did you claim?
No
Yes
When did you go in?
No
Yes
When did you go in?
No
Yes
If your nationality is not British,
on what date did you last arrive
in the UK?
What is your nationality?
The UK is England, Northern
Ireland, Scotland and Wales.
Are you or your partner in
hospital at the moment?
Please give their name and address.
No
Yes
Please give their name and address.
No
Yes
Does anyone get Carer’s
Allowance for looking after you
or your partner?
Please tick ‘Yes’ if you or your
partner have been told you are
entitled to Carer’s Allowance even
though you do not get it, because
you are getting another benefit
instead.
Please tick if you or your partner
are:
• a student
• a former resident of a
homeless hostel
• an apprentice
• on youth training
• in legal custody
• severely mentally impaired
• registered blind
• long-term sick or disabled
and incapable of work
You
Your partner
Postcode:
Postcode:
Postcode:
Postcode:
/
/
/
/
Nationality
Nationality
/
/
/
/
/
/
/
/
When do you expect to come out?
When do you expect to come out?
/
/
/
/
2
We will contact you if we need any more information.
Part 2
About children
Are there any children in your
household as described?
Last name
Tell us about the children you want to claim for. If you want to
claim for more than 3 children, use a separate sheet of paper.
Go to Part 3.
First child
If you are sending a separate sheet of paper, tick this box.
No
Yes
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, SCE Higher level or GNVQ (advanced).
Second child
Third child
Other names
Date of birth
What is the child’s sex?
The child’s relationship to you
Child Benefit number
Who gets the Child Benefit for
them?
We need to see proof of this.
3
/
/
/
/
/
/
Tell us the name and
registration number
of the minder.
How much do you pay a week?
We need to see proof.
We need to see proof.
We need to see proof.
How much do you pay a week?
How much do you pay a week?
Tell us the name and
registration number
of the minder.
Tell us the name and
registration number
of the minder.
No
Yes
Is the child registered blind
or getting Disability Living
Allowance?
Read the Checklist at Part 17 to see what you can use as proof.
No
Yes
No
Yes
No
Yes
Do you pay any childminding
costs for this child?
For example, to a childminder,
nursery or after-school club.
No
Yes
No
Yes
£
£
£
Part 3
About other people who live with you
Do any adults normally live
with you and your partner?
By adults we mean people
over 16 who nobody gets
Child Benefit for.
Last name
Are any of the people who
normally live with you married
to each other or living together
as if they were married?
Now tell us about all the people
who normally live with you and
your partner.
Tell us about all the adults, except your partner, who
usually live with you. If you want to tell us about more than 3
people, use a separate piece of paper.
Go to Part 4.
First person
If you are sending a separate sheet of paper, tick this box.
No
Yes
Tell us their names.
is the partner of
No
Yes
Second person
Third person
Other names
Date of birth
Do they get Income Support,
income-based Jobseeker’s
Allowance, Pension Credit or
Employment Support Allowance
(Income Related)?
Their relationship to you
For example, aunt, brother,
daughter, father, grandson,
grandmother, stepdaughter,
joint tenant, joint owner
or friend.
National Insurance Number
We can make a decision on your
claim quicker, if you give us this
information.
4
/
/
/
/
/
/
And
is the partner of
No
Yes
No
Yes
No
Yes
Do they get Disability Living
Allowance or Attendance
Allowance, or are they
registered blind?
No
Yes
No
Yes
No
Yes
Are they a full-time student, a
student nurse, a care worker, an
apprentice or on youth training?
No
Yes
No
Yes
No
Yes
Do they pay rent to you
or your partner?
No
Yes
No
Yes
No
Yes
Letters
Numbers
Letter
Letters
Numbers
Letter
Letters
Numbers
Letter
Part 3
About other people who live with you -
continued
Are they severely
mentally impaired?
5
No
Yes
No
Yes
No
Yes
Are they in legal custody
at the moment?
No
Yes
No
Yes
No
Yes
/
/
/
/
/
/
When are they
expected to come
out?
When are they
expected to come
out?
When are they
expected to come
out?
Do they normally work for
16 hours or more a week?
No
Yes
No
Yes
No
Yes
£
£
£
We need to see proof
of their earnings.
We need to see proof
of their earnings.
We need to see proof
of their earnings.
Tell us their
earnings before
deductions for
things like tax and
National Insurance.
Tell us their
earnings before
deductions for
things like tax and
National Insurance.
Tell us their
earnings before
deductions for
things like tax and
National Insurance.
Do they have any other
income at all?
No
Yes
No
Yes
No
Yes
£
£
£
We need to see proof
of their income.
We need to see proof
of their income.
We need to see proof
of their income.
Tell us their other
income before
deductions for
things like tax and
National Insurance.
Tell us their other
income before
deductions for
things like tax and
National Insurance.
Tell us their other
income before
deductions for
things like tax and
National Insurance.
Are they in hospital
at the moment?
No
Yes
No
Yes
No
Yes
/
/
/
/
/
/
When did they
go in?
/
/
/
/
/
/
When are they expected to
come out?
When are they expected to
come out?
When are they expected to
come out?
When did they
go in?
When did they
go in?
Read the Checklist at Part 17 to see what you can use as proof.
Part 4
About rent
Do you own your own home or
have a mortgage?
Answer the next question.
6
No
Yes
Please tick to show if the
property is let as:
furnished
partly furnished
minimally furnished
unfurnished
Are you a council tenant?
When did you start renting your
home?
No
Yes
/
/
How long is the tenancy for?
/
/
When is the next rent increase
due?
/
/
/
/
When did you move to this
address?
If you have not moved in yet, tell
us when you expect to move in.
What sort of tenancy do you
have?
For example, shorthold, tied rent or
something like this.
/
/
Go to Part 6.
Answer the questions below.
Does anyone else share the rent
with you and your partner?
No
Yes
Tell us their names.
Has your rent changed
in the last 12 months?
No
Yes
Has your rent been registered as
a fair rent by the rent officer?
Please send us the notice of registration form R05.
No
Yes
Send us proof of the date it changed, and by how much it changed.
Go to Part 5.
to
How much rent are you
charged?
£
every
(week/2 weeks/4 weeks/month)
Part 4
About rent -
continued
Do you have any weeks when
you do not have to pay rent?
7
No
Yes
Are you behind with your rent?
How many?
No
Yes
By how much?
By how many weeks?
Tell us who pays the Council Tax.
/
/
Do you pay water charges
direct to the water authority?
No
Yes
Are you living away from this
address at the moment?
No
Yes
Tell us why you are not living there.
When did you last live there?
/
/
When do you expect to go back there?
If your home has been sublet, tell us who lives there now.
Tell us the address of where you are living at the moment.
Postcode
Who pays the Council Tax
on your home?
Please tick the appropriate box.
You and your partner
Your landlord
Someone else
£
Part 4
About rent -
continued
Does your rent include
money for the following?
Meals
Heating
8
No
Yes
How much?
Which meals
are included?
£
No
Yes
How much?
£
Lighting
No
Yes
How much?
£
Hot water
No
Yes
How much?
£
Fuel for cooking
No
Yes
How much?
£
Laundry
No
Yes
How much?
£
General counselling
and support
No
Yes
How much?
£
Emergency alarm
No
Yes
How much?
£
Room and window cleaning
No
Yes
How much?
£
Central heating
No
Yes
How much?
£
Internal decoration
No
Yes
How much?
£
Gardening
No
Yes
How much?
£
Garage or parking space
No
Yes
No
Yes
If ‘Yes’, do you have to rent the garage
or parking space as part of your tenancy
agreement?
Part 4
About rent -
continued
What is your landlord’s
name and address?
By landlord we mean the person or
organisation who owns the property
you live in.
9
Postcode
If your landlord has an agent,
tell us their name and address.
By agent we mean the person or
organisation you actually pay your
rent to.
Are you, your partner or
children related to your landlord
or agent, or to your landlord’s
partner or your agent’s partner?
Related includes related through
marriage, even if the marriage has
ended.
Postcode
What is the relationship?
No
Yes
We must see proof of your rent and tenancy before we can decide how much
benefit you can get. Read the checklist at Part 17 to see what you can use as
proof.
What sort of building do
you live in?
How many floors are there?
Detached house
Semi-detached
house
Terraced house
Maisonette
Bungalow
Flat in house
Flat in block
Flat over shop
Bedsits or rooms
Hostel
Hotel
Board and lodgings
Caravan, mobile
home or houseboat
Residential nursing
home
Residential care
home
Other
Do you and your household
occupy only part of the building
you have listed above?
As you look at the building from the street, where in the building do you live?
At the left
At the right
In the front
In the middle
At the back
No
Yes
Which floors do you live on?
For example, ground floor, first floor
Part 5
About where you live
10
How many rooms are there
in the building?
Living rooms
Bedsitting rooms
Bedrooms
Bathrooms
Toilets
Kitchens
Other rooms
Do you use your
home for business?
Please tell us if you have any
special needs that require you
to rent a home of this size
No
Yes
In the whole
building?
Just for you and
your household?
That you share with
other people?
Do you or your partner have a
carer that stays overnight?
If Yes
No
Yes
Do they have their own
bedroom?
Who do they provide care for?
Why is the care required?
How often does the carer stay?
No
Yes
Part 5
About where you live -
continued
11
Do you have a main home
somewhere else?
If your main home is
somewhere else in the UK or
abroad, tick ‘Yes’, even if you do
not pay rent on it.
No
Yes
What is the address?
Postcode
How much do you pay for this home?
£
Part 6
About Income Support, income-based
Jobseeker’s Allowance, income related
Employment and Support Allowance and
Pension Credit
Are you or your partner
getting or waiting to hear about
a claim for Income Support,
income-based Jobseeker’s
Allowance, income related
Employment and Support
Allowance or Pension Credit?
Are you or your partner
getting Income Support,
income-based Jobseeker’s
Allowance, income related
Employment and Support
Allowance or Pension Credit?
No
Yes
No
Yes
Answer both the questions in this part, then go to
Part 7.
When did you start
getting it?
Go to Part 7.
You
/
/
No
Yes
When did they start
getting it?
Your partner
/
/
Are you or your partner still
waiting to hear about a claim
for Income Support, income-
based Jobseeker’s Allowance,
income related Employment and
Support Allowance or Pension
Credit?
No
Yes
When did you
claim?
/
/
No
Yes
When did they
claim?
/
/
Part 7
About being self-employed
12
Are you or your partner
self-employed?
What kind of work do you do?
When did the business start?
What is the business address?
No
Yes
Are you or your partner
a company director?
No
Yes
You
Answer the questions on this page.
You must send us your trading accounts for the last financial year.
If you have only recently set up the business and 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.
Are there any other partners
in the business?
How many hours a week
do you work?
No
Yes
Tell us their name
and address.
Do you get a Business
Start-up Allowance?
No
Yes
How much?
How often?
£
Go to Part 8.
/
/
Postcode
Postcode
Every
Do you pay into a private
pension scheme?
No
Yes
How much?
How often?
£
Every
Your partner
No
Yes
Tell us their name
and address.
No
Yes
How much?
How often?
£
/
/
Postcode
Postcode
Every
No
Yes
How much?
How often?
£
Every
We must see proof of any earnings before we can decide how much benefit
you can get. Read the checklist at Part 17 to see what you can use as proof.
Part 8
About working for an employer
13
Do you or your partner work for
an employer?
What kind of work do you do?
When did you start this job?
What is your employer’s
name and address?
No
Yes
You
Answer the questions on this page. If you work for more than one employer,
tell us about all the employers on another piece of paper and send it with this
form.
Are you employed for a
limited period?
How often do you get paid?
How much do you get paid?
When was your last pay rise?
How many hours a week
do you usually work?
No
Yes
When will you
finish?
Are you getting Statutory Sick
Pay (SSP) or Statutory Maternity
Pay (SMP) from your employer
at the moment?
If Yes, when did this start?
No
Yes
Go to Part 9.
/
/
Postcode
Your partner
No
Yes
When will they
finish?
No
Yes
Are you getting any other sick
pay or maternity pay from your
employer at the moment?
No
Yes
No
Yes
Do you pay into a private or
company pension scheme?
No
Yes
No
Yes
/
/
/
/
How are wages paid i.e. Bank
account?
/
/
/
/
/
/
When will your next pay rise be?
/
/
/
/
/
/
/
/
Postcode
We must see proof of any earnings before we can decide how much benefit
you can get. Read the checklist at Part 17 to see what you can use as proof.
If you get tips or bonuses, tell us about these in Part 15.
If you are sending a separate sheet of paper, tick this box.
£
£
Every
Every
How much?
How much?
£
£
Every
Every
Part 9
About any other work
14
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.
What kind of work do you do?
When did you start this work?
What is the name and address
of the person you do this work
for?
No
Yes
You
Answer the questions on this page.
Do you get paid?
If you only get expenses or tips,
still tick ‘Yes’ and give details.
No
Yes
How much?
Go to Part 10.
/
/
Postcode
Your partner
No
Yes
How much?
/
/
Postcode
We must see proof of any earnings before we can decide how much benefit
you can get. Read the checklist at Part 17 to see what you can use as proof.
£
£
Every
Every
How many hours a week
do you work?
When will your next pay rise be?
/
/
/
/
Part 10
About benefits and pensions
15
Are you or your partner getting
any benefits or waiting to hear
about benefits you have
claimed?
Read the list of benefits and tell us
about any you or your partner are
getting now or have claimed.
No
Yes
• Attendance Allowance
• Adoption Pay
• Bereavement Allowance
• Carer’s Allowance
• Child Benefit
• Disability Living Allowance
• Disabled Person’s Tax Credit
• Fostering Allowance
• Guardian’s Allowance
• Incapacity Benefit
• Industrial Injuries Disablement Benefit
• Industrial Death Benefit
• Contribution-based Jobseeker’s Allowance
• Maternity Allowance
• Pension Credit
• Retirement Pension
• Severe Disablement Allowance
• Statutory Maternity Pay
• Statutory Paternity Pay
• War Disablement Benefit, War Pension
or War Widow’s Pension
• Widow’s or Widower’s Benefits
• Working Tax Credit
• Children’s Tax Credit
• Statutory Sick Pay
• Any other social security benefit
The name of the benefit or
pension
Waiting to hear
Getting now
You
How much?
How often and by what method?
Tell us about the
benefits below.
Go to Part 11.
If you are getting or have claimed any benefit that is not listed,
tell us about it on a separate page and send it with the form.
£
Every
by
The name of the benefit or
pension
Waiting to hear
Getting now
How much?
How often and by what method?
£
Every
by
The name of the benefit or
pension
Waiting to hear
Getting now
How much?
How often and by what method?
£
Every
by
If you are sending a separate sheet of paper, tick this box.
We need to see proof.
Your partner
How much?
How often and by what method?
£
Every
by
How much?
How often and by what method?
£
Every
by
How much?
How often and by what method?
£
Every
by
We need to see proof.
Part 11
About other money coming in
16
Do you or your partner, or any
children you are claiming for,
have any money coming in that
you have not already told us
about on this form?
No
Yes
What is the money for?
Answer the questions
on this page.
No
Yes
What for?
How much?
Go to Part 12.
This includes occupational pensions, student income such as grants,
loans or bursaries, maintenance or child support for you, your partner or
any of the children you have told us about on this form; and any cash
payments. Also tell us about any money you get from people living in
your house as boarders, lodgers or subtenants. You do not need to tell us
about payments from the Independent Living Fund, the Eileen Trust or the
MacFarlane Trust.
Who gets it?
How much do they get?
How often?
£
Every
Other money 1
What is the money for?
Who gets it?
How much do they get?
How often?
£
Every
Other money 2
What is the money for?
Who gets it?
How much do they get?
How often?
Does anyone owe money to
you, your partner, or any
children you are claiming for?
£
£
Every
Other money 3
We must see proof of any earnings before we can decide how much benefit
you can get. Read the checklist at Part 17 to see what you can use as proof.
Part 12
About bank accounts, savings, investments and
property
17
Do you or your partner have
any savings, investments or own
or partly own any land or
property other than the home
you live in?
This includes current accounts and
savings accounts with a bank or
building society, post office
accounts, Premium Bonds or stocks
and shares.
No
Yes
Answer all the questions in this part. We must see proof
of all the capital, savings and investments. Read the
checklist at Part 17 to see what you can use as proof.
No
Yes
Tell us about bank accounts. If there are more than
2 bank accounts, tell us about the others on a separate
piece of paper and send it with this form.
Name of bank
Go to Part 13.
Do you or your partner have
any bank accounts?
Whose name is the account in?
Name of bank
Whose name is the account in?
Account number
How much is in the account?
Account number
How much is in the account?
£
£
If you are sending a separate sheet of paper, tick this box.
No
Yes
Tell us about building society accounts. If there are more than
2 building society accounts, tell us about the others on a separate
piece of paper and send it with this form.
Name of building society
Do you or your partner have
any building society accounts?
We need proof of all your accounts, even those with little or no money,
or this may delay paying your benefit.
Whose name is the account in?
Name of building society
Whose name is the account in?
Account number
How much is in the account?
Account number
How much is in the account?
£
£
If you are sending a separate sheet of paper, tick this box.
Part 12
About bank accounts, savings, investments and
property
18
No
Yes
Tell us about post office accounts. If there are more than
2 post office accounts, tell us about the others on a separate
piece of paper and send it with this form.
Type of account
Do you or your partner have
any post office accounts?
This includes savings accounts and
Girobank accounts.
Whose name is the account in?
Type of account
Whose name is the account in?
Account number
How much is in the account?
Account number
How much is in the account?
£
£
£
If you are sending a separate sheet of paper, tick this box.
No
Yes
Value
Do you or your partner have
any Premium Bonds?
No
Yes
Tell us about National Savings Certificates. If you have more than
2 issues, tell us about the others on a separate piece of paper
and send it with this form.
No
Yes
Company name
Do you or your partner have
any National Savings
Certificates?
Do you or your partner have
any stocks, shares, bonds or unit
trusts?
Issue number
Value
How many?
£
Issue number
Value
How many?
How many?
Company name
Approximate value
How many?
£
If you are sending a separate sheet of paper, tick this box.
£
Approximate value
£
We need proof of all your accounts, even those with little or no money,
or this may delay paying your benefit.
Part 12
About bank accounts, savings, investments and
property
19
No
Yes
Tell us about this.
Do you or your partner have
any other capital, savings or
investments?
Tell us about any TESSAs or ISAs
here.
No
Yes
We will write to you about it.
Do any of your or your partner’s
savings or investments include:
• money from the sale of a house, or
• money from a charity?
No
Yes
We will write to you about it.
Have you or your partner
received a payment from the
CJD (Creutzfeldt-Jakob Disease)
Trust?
No
Yes
What payment did you receive? Who received the payment?
A Far Eastern Prisoner of War
Compensation payment
You
Your partner
A compensation payment made
to victims of atrocities that
happened during the
Second World War
You
Your partner
Have you or your partner
received:
• a Far Eastern Prisoner of War
Compensation payment, or
• a compensation payment made to
victims of atrocities that happened
during the Second World War?
We need to know this to make
sure we do not count it as part of
your savings.
No
Yes
We will write to you about it.
Apart from your home, do you
or your partner own any other
property or land in this country
or abroad?
If it is on a mortgage or a loan,
still tick Yes.
Do you, your partner have any
other savings or investments?
Type of account
Whose name is the account in?
Account number
How much is in the account?
£
Type of account
Whose name is the account in?
Account number
How much is in the account?
£
Part 13
How you will be paid
20
Tell us the following details.
How do you want us to pay
your Housing Benefit?
We can pay your Housing Benefit
straight into your bank or building
society account or in certain cases
straight to your landlord.
Payments direct into a bank or building society account is the safest way to
pay your Housing Benefit.
•
If you are a tenant of a private landlord, your Housing Benefit will be
paid to you.
You cannot choose to pay your landlord but if there is a reason why
you cannot manage your own payments you should tell us why on a
separate sheet of paper. You will normally need to supply evidence
from for example your Doctor, Support Worker or a Welfare
Organisation confirming the reasons why you cannot manage.
•
If you are a tenant of a Housing Association, your Housing Benefit will
be paid to you unless you choose to have it paid to your landlord.
•
If you are a council tenant, your Housing Benefit will be paid into your
rent account.
•
If you are awarded Council Tax Benefit or a Council Tax Reduction,
this will be paid into your Council tax account.
I want my benefit to go straight
into my bank or building society
account.
Name of bank or building
society
Address
Whose name is the account in?
Account number
Sort code
I want my benefit to go straight
to my landlord.
Please make sure this account is included in Part 12 of this form.
Postcode
Private tenants cannot choose to have payments made to their
landlords.
Part 14
Sharing information
21
Sharing information with your landlord or representative could help us deal with
your claim quicker and reduce the risk of you falling behind with your rent. It
will not affect your claim if you do not wish to give us permission to disclose
details of your claim to your landlord. You can also withdraw your permission at
any time.
If you give us permission, we would be able to tell your landlord or representative:
• If you have claimed Housing Benefit
• If we have made a decision on your claim and what the decision is
• If we need more information to make a decision on your claim
• When a payment was made, the period the payment was for
• If your claim has ended or has been suspended
We would also write to your landlord to advise that your claim had been
completed and the date payment will be sent.
We will not give your landlord or representative any information about your
financial or personal circumstances.
If you do not give us permission we will only share information with your
landlord if your Benefit is paid directly to them. We will tell them the amount of
benefit to be paid, the period that it covers and the date it is due to be sent.
We would not be able to give information to a representative who may be acting
on your behalf if you do not give us permission.
To give us permission to discuss your claim with your landlord or representative,
please sign below and return the form to The Benefit Section, Freepost CF429,
PO Box 6000, Cardiff, CF11 0WZ or in person to The First Stop Enquiry Centre,
Marland House, Central Square, Cardiff CF10 1EP. Or any Local Area Housing
Office.
I give Cardiff Council Benefit Section permission to share information about the
progress of my Housing Benefit claim with my landlord or a representative
acting on my behalf.
Customer Signature
Full name
(IN CAPITAL LETTERS)
Address
Landlord’s name
Representative’s name and organisation
Address
Address
Tel No:
Tel No:
Part 15
Anything else you need to tell us
22
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 sheet of paper, tick this box.
Part 16
Backdating
Date you want to claim
benefit from
During this earlier period, were
your circumstances different to
those you have told us about on
this form?
What has changed?
We need proof of changes in your
circumstances for this period.
Why have you not claimed
before?
/
/
We will normally award your entitlement from the first Monday after we receive
this form. If you want us to pay you from an earlier date, fill in the boxes below.
You need to tell us:
• Why you did not claim earlier. We can only backdate if you have good
reasons why you did not claim earlier.
• The date you want to claim from. If you have good reasons why you did
not claim earlier we will normally pay you from the first Monday after this
date.
If you need more space, send a separate sheet of paper
and tick this box.
No
Yes
Please tell us about it below
Part 17
Checklist
23
Please tick to tell us what proof you
are sending with this form. We
must see original documents, not
copies.
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 other 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.
Please do not send valuable items
through the post. If you can, bring
them into one of our reception
areas. The address is on the second
page of the information sheets that
are attached to the front of this
form. We will take the details we
need and give you the documents
back straight away. If you cannot
get into the office, phone us for
more advice.
Proof of identity
We need to see at least two of these documents for each person, and one of the
documents must show the National Insurance number.
Such as a:
• birth certificate;
• marriage certificate;
• passport;
• National Insurance number card;
• medical card;
• driving licence;
• UK residence permit;
• EEC identity card; or
• recent gas or electricity bill.
We need to see at least 2 of these documents for each person.
Proof of bank accounts, savings, investments and property
This means:
• all your bank, building society or post office books,
or certificates for Premium Bonds;
• your bank statements, showing details for the last 2 months, printouts from
internet banking are acceptable;
• National Savings Certificates; or
• ISAs, stocks, shares and unit trusts.
We need to see proof on any interest or dividends you get on investments
and savings.
Proof 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 these payslips, ask your employer to fill in the
Certificate of earned income on page 25. If you or your partner are
self-employed, we need to see your accounts, preferably audited by your
accountant for the last financial year or, if you have been trading for less than 6
months, a summary of your trading records so far.
Proof of other income
Such as pension slips from a former employer or a letter from the court showing
how much maintenance you are getting. We need to see proof of any money
people pay you for board and lodgings.
Proof of benefits, allowances or pensions
Such as award notices or letters from social security confirming how much you
get. If you do not have proof, let us know straight away.
Proof of private rent and tenancy
Such as a tenancy agreement with either rent receipts, consecutive bank
statements showing rent paid, your rent book or a letter from your landlord or
agent. The letter or rent book should show the rent paid so far or the outstanding
arrears. You may also ask your landlord to fill in the proof of rent form on page
27. If you have to send the proof of rent form to your landlord to fill in, do not
delay in sending the rest of the form back to us.
Proof of other money paid out
Such as letters about student grants or maintenance, agreements or receipts from
registered child carers.
24
Even if someone else has filled
in this form for you, you must
sign this declaration if you can.
If you have a partner, getting
them to sign this form should
allow us to process your claim
more quickly, but they do not
have to sign.
Signature of person claiming
Date
/
/
Partner’s signature
Date
Name of the person who
filled in the form.
If this form has been filled in by
someone other than the person
claiming:
Please tell us why you are filling
in this form for the person
claiming.
Relationship to the
person claiming
Signature of the person
/
/
Date
This authority is under a duty to protect the public funds it administers, and to this end
may use the information you have provided on this form for the prevention and detection
of fraud. It may also share this information with other bodies responsible for auditing or
administering public funds for these purposes.
For further information, see our Fair Processing Notice Condensed Text at
www.cardiff.gov.uk/fraud and the Fair Processing Notice Full Text on the Wales Audit
Office website www.wao.gov.uk/whatwedo/1252.asp
Or contact:
Phillip Bradshaw, Information Manager, CY4B County Hall, Cardiff CF10 4UW
Telephone: (029) 2087 3346. Fax: (029) 2087 3349
Email: pbradshaw@cardiff.gov.uk
/
/
Please read this declaration carefully before you sign and date it.
• I understand that this claim is made to you, Cardiff County Council.
• I declare that the information I have given on this form is correct and
complete as far as I know and believe.
• I understand that if I knowingly give information that is incorrect or
incomplete, I may be liable to prosecution or other action.
• I agree that you will use the information I have provided to process my
claim. You may contact other sources such as my employer to check
this information.
• I understand that you may use any information I have provided in
connection with this and any other claim for social security benefits
that I have made or may make. You may give some information to other
organisations, such as government departments, local authorities and
private-sector companies such as banks and organisations that may lend
me money, if the law allows this.
• I know that I must let you know in writing straight away about any
change in my circumstances which might affect my claim.
Part 18
Declaration
25
Under the Race Relations Act we have a responsibility to gather details of
our clients’ backgrounds. This information is used to help us with our
equal opportunities policies.
This information is confidential and will be used only to improve access to
our services and help provide equal opportunities for everyone.
The completion of this survey is voluntary.
Questionnaire
Ethnic Origin
Which background do you
feel you belong to?
White
British
Irish
European
Other white
background
please specify
Black
African
African Somali
British
Caribbean
Other black
background
please specify
Asian
Bangladeshi
British
Indian
Pakistani
Sri Lankan
Other Asian
background
please specify
Mixed Ethnic Background
White and Asian
White and Black African
White and Black Caribbean
Other mixed ethnic
background
please specify
Other Groups
Arab
British Chinese
Chinese
Czech
Gypsy Traveller
Japanese
Korean
Polish
Somali
Yemeni
Other background
please specify
Any Other Ethnic
Background
Any other ethnic
background
please specify
Nationality
Do you consider yourself to be
Welsh?
No
Yes
26
Employee details (person claiming benefit)
Employee’s name
Employee’s address
including postcode
Employee’s number
Occupation
Cardiff County Council
Housing Benefit/Council Tax Benefit/Council Tax
Reduction Certificate of earned income
We may contact your employer direct if we have a query with the information provided
Please give this form to your employer to complete
Employer details (who you work for)
Name
Employer’s
authorisation stamp
or attach a letterhead
Position
Business Name and
address
Income details
Date employment
started
Normal hours
Date employment
Ended (if applicable)
per week
Tax Code
/ /
/ /
National Insurance
Number
Normal basic pay
£
per
Date of last pay
increase
/ /
Date of next
expected increase
/ /
Do they currently
get sick pay or
maternity pay?
Yes
No
If ‘Yes’, what do
they receive, when
from, and when is
it due to expire?
27
How are they
paid?
by cash
by cheque
into a bank account
other (please detail)
How often are
they paid?
every week
every two weeks
every four weeks
every month
other (please detail)
Telephone Number
Telephone Number
28
Recent Income
In the table below. please give details of the employees last 5 payslips if paid weekly, last 2
payslips if paid monthly and last 3 if paid fortnightly. Include any overtime, bonuses, commission
and so on.
Pay period starting
Pay period ending
Number of hours worked
Payment 1
Payment 2
Payment 3
Payment 4
Payment 5
Payments
Gross Earnings
Sick Pay
Overtime
Maternity Pay
Other payments
(please detail)
Deductions
Tax
National Insurance
Pension
Net Payment
Year To Date
Year To Date
Do your employees
earnings vary a lot?
Yes
No
If ‘Yes’ please show the total earnings and deductions for the last 13 weeks or 3 months (or if they
have not been employed that long – as long as possible). Include overtime, bonuses, commission,
etc.
Period start Period end
Hours
worked
Tax
National
Insurance
Pension
Contributions
If your employee has recently started work
Please complete this section if your employee has started work in the last two months
Have normal hours
been worked since
starting work?
Yes
No
If ‘No’ what hours are
they currently working
and when will they start
normal hours?
Is your employee
expected to earn any
additional money on top
of their normal wages?
eg. bonus,
regular overtime, etc.
If so please provide
details
Declaration
What to do now
The information I have given the Council is true and complete
Signature
Date
Please post this form to:
Cardiff County Council
Benefits Section
Freepost CF429
PO Box 60000
CF11 0WZ
Private and Confidential
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
Gross
Payments
£
£
£
£
Tenant details
Landlord and tenancy details
29
I would be grateful if you could help your tenant
by filling in this form and returning it to me.
Tenant’s name
Address and
postcode
Landlord’s details
Name
Address and
postcode
Please tell us about your agent
if you have one.
Agent’s details
Name
Tenancy details
Are you related to
the tenant, their
partner or their
children?
Is this a tenancy
where the agent only
acted for a finding fee?
Date the tenant
moved in
Date the tenancy
started
Is there a joint
tenancy?
How much rent do
you charge for each
tenant if it is a joint
tenancy?
How often is the
rent due?
Has the rent officer
registered a fair
rent?
Relationship
No
Yes
Address and
postcode
Cardiff County Council
Proof of rent form
No
Yes
Number of tenants
No
Yes
No
Yes
/
/
How much rent do
you charge?
/
/
/
/
/
/
£
£
By how much?
Meals
Landlord and tenancy details - continued
No
Yes
By how many weeks?
£
£
Heating
£
Lighting
£
Emergency alarm
£
Fuel for cooking
£
Room and window cleaning
£
General counselling and support
£
Laundry
£
Central heating
£
Internal decorating
£
Garage or parking space
£
Gardening
£
Water rates
£
Hot water
£
Other
Please
specify
£
(weekly/2 weekly/4 weekly/monthly)
Is the tenant behind
with their rent?
Services
Does your rent
include money for
any of the following?
Declaration
As far as I know, the information I have
given is correct. I will write to you
immediately if I know that my tenant’s
circumstances have changed.
Signature
Date
Declaration for
direct payments
I will accept Housing Benefit for this tenant.
If you pay me too much, I understand you
may ask me to pay it back and take me to
court if I don’t. I will write to you
immediately if I know that my tenant’s
circumstances have changed.
Signature
Date
What to do now
Please post this
form to:
Cardiff County Council
Benefits Section
Freepost CF429
PO Box 6000
Cardiff
CF11 0WZ.
Private and confidential
(For your landlord or agent to fill in)
Please sent us the notice of
registration form R05.
30
Housing Benefit/Council Tax Benefit/Council Tax Reduction
Change of Circumstances Form
31
Name
Address
Cardiff County Council
Name
Relationship to claimant /
organisation
Telephone Number
Claim Reference:
Date of Change
Telephone Number
Postcode:
Details of the change
(continue on a separate sheet
if necessary)
If you are not the claimant
please complete this section:
I understand that if I give information that is incorrect or incomplete, you may
take action against me. This may include court action.
I declare that the information I have given on this form is correct and complete.
Please keep this form and return it to The Benefits Section with details of any
changes in your circumstances.
You will need to provide proof of the change. Please provide original
documents as we do not accept photocopies.
Return this form immediately, do not delay telling us about the change
even if you do not yet have the proof.
How to return this form:
• By Post to: The Benefits Section, Freepost CF429, PO Box 6000,
Cardiff CF11 0WZ
• In Person to: First Stop Enquiry Centre, Ground Floor,
Marland House, Central Square.
• Or contact us on: 029 2087 2087 for a surgery near you.
/
/
Signature
Date
/
/
32
Changes in Circumstances
You must tell the The Council’s Benefits Section about any changes in your circumstances that
could change the amount of you receive.
The changes you should tell us about include, but are not limited to:
•
If you change address
•
If you or your partner start work, change job or have a pay increase
•
If there is any change to any income, that you or your partner receive
•
If any welfare benefits change such as tax credits
•
If Job Seekers Allowance or Income Support stops
•
If one of your children leaves school or the birth of a baby
•
If anyone moves in or out of the property, even on a temporary basis
•
If you have a new partner or become married or separated
•
A change in your savings, only if they are above £6000 in total
•
If you start or stop paying childcare costs or if the amount changes
•
If your rent changes (unless you are a council tenant)
•
If anyone in your home has a change of circumstances
If you are required to register your employment with the Home Office remember to tell them if
you change your job and tell us too.
Please note these are just examples and you should tell us about any change that might affect
your benefit straightaway. If you are not sure, please contact us for advice.
You must tell the Council’s Benefits Section about the changes. Do not rely on someone else to
pass the message on and do not just tell the Job Centre or the Pension Service.
If it’s New Tell Us Too!
Overpaid Benefit
If you delay in telling us about a change of circumstances an overpayment of benefit may result.
You will have to pay this money back and legal action may be taken if you do not do so.
You may be prosecuted if you deliberately fail to declare changes in your circumstances.
If you have difficulty in understanding this form, help is available in many languages at the
First Stop Enquiry Centre, Marland House, Central Square, Cardiff.
V
ersion 9 Mar
ch 2013
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