Cardiff County Council
A claim form for Housing Benefit/
Council Tax Benefit/Council Tax Reduction
Are you (please tick one box):
a council tenant? an owner-occupier?
a private tenant? 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 No
For official use Receipt Stamp
normally lives with you?
Date issued
By partner we mean If you have a partner,
Yes
" a person you are married to or a person
you must answer all
you live with as if you are married to
the questions about
them, or
them.
" a civil partner or a person you live with
as if you are civil partners
You Your partner
Last name
Other names
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.
Postcode:
Postcode:
Date of birth // //
National Insurance number
You can find this on payslips or
Letters Numbers Letter Letters Numbers Letter
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.
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.
Postcode:
Postcode:
// //
Have you or your partner come to
No No
live in England, Northern Ireland,
Scotland, Wales, the Republic of
Yes Yes
Ireland, the Channel Islands or the
We will write to you about this. We will write to you about this.
Isle of Man in the last 5 years?
1
Part 1 About you and your partner - continued
You Your partner
If your nationality is not British,
on what date did you last arrive // //
in the UK?
Nationality Nationality
What is your nationality?
The UK is England, Northern
Ireland, Scotland and Wales.
Have you or your partner No No
claimed Housing Benefit/
Council Tax Benefit/Council Tax Yes Yes
When did you claim? When did you claim?
Reduction within the last 5
years?
// //
What address did you claim for? What address did you claim for?
Postcode: Postcode:
Are you or your partner in
No No
hospital at the moment?
Yes Yes
When did you go in? When did you go in?
// //
When do you expect to come out? When do you expect to come out?
// //
Does anyone get Carer s
No No
Allowance for looking after you
or your partner?
Yes Yes
Please tick  Yes if you or your Please give their name and address. Please give their name and address.
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.
Postcode: Postcode:
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
We will contact you if we need any more information.
2
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, SCE Higher level or GNVQ (advanced).
No
Are there any children in your Go to Part 3.
household as described?
Tell us about the children you want to claim for. If you want to
Yes
claim for more than 3 children, use a separate sheet of paper.
If you are sending a separate sheet of paper, tick this box.
First child Second child Third child
Last name
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.
No No No
Is the child registered blind
or getting Disability Living
Yes Yes Yes
Allowance?
No No No
Do you pay any childminding
costs for this child?
Tell us the name and Tell us the name and Tell us the name and
For example, to a childminder, Yes Yes Yes
registration number registration number registration number
nursery or after-school club. of the minder. of the minder. of the minder.
How much do you pay a week? How much do you pay a week? How much do you pay a week?
ŁŁŁ
We need to see proof. We need to see proof. We need to see proof.
Read the Checklist at Part 17 to see what you can use as proof.
3
Part 3 About other people who live with you
Do any adults normally live
No
Go to Part 4.
with you and your partner?
By adults we mean people
Tell us about all the adults, except your partner, who
Yes
over 16 who nobody gets
usually live with you. If you want to tell us about more than 3
people, use a separate piece of paper.
Child Benefit for.
If you are sending a separate sheet of paper, tick this box.
Are any of the people who
No
normally live with you married
to each other or living together
Yes
as if they were married? Tell us their names. is the partner of
And is the partner of
Now tell us about all the people
who normally live with you and
your partner.
First person Second person Third person
Last name
Other names
Date of birth
/ / / / / /
Their relationship to you
For example, aunt, brother,
daughter, father, grandson,
grandmother, stepdaughter,
joint tenant, joint owner
or friend.
National Insurance Number
Letters Numbers Letter Letters Numbers Letter Letters Numbers Letter
We can make a decision on your
claim quicker, if you give us this
information.
Do they get Income Support,
No No No
income-based Jobseeker s
Allowance, Pension Credit or
Yes Yes Yes
Employment Support Allowance
(Income Related)?
Do they get Disability Living
No No No
Allowance or Attendance
Allowance, or are they
Yes Yes Yes
registered blind?
Are they a full-time student, a
No No No
student nurse, a care worker, an
apprentice or on youth training?
Yes Yes Yes
Do they pay rent to you
No No No
or your partner?
Yes Yes Yes
4
Part 3 About other people who live with you - continued
Are they severely
No No No
mentally impaired?
Yes Yes Yes
Are they in legal custody
No No No
at the moment?
When are they When are they When are they
expected to come expected to come expected to come
Yes Yes Yes
out? out? out?
/ / / / / /
Are they in hospital
No No No
at the moment?
When did they When did they When did they
Yes go in? Yes go in? Yes go in?
/ / / / / /
When are they expected to When are they expected to When are they expected to
come out? come out? come out?
/ / / / / /
Do they normally work for
No No No
16 hours or more a week?
Tell us their Tell us their Tell us their
earnings before earnings before earnings before
Yes Yes Yes
deductions for deductions for deductions for
things like tax and things like tax and things like tax and
National Insurance. National Insurance. National Insurance.
ŁŁŁ
We need to see proof We need to see proof We need to see proof
of their earnings. of their earnings. of their earnings.
Do they have any other
No No No
income at all?
Tell us their other Tell us their other Tell us their other
income before income before income before
Yes Yes Yes
deductions for deductions for deductions for
things like tax and things like tax and things like tax and
National Insurance. National Insurance. National Insurance.
ŁŁŁ
We need to see proof We need to see proof We need to see proof
of their income. of their income. of their income.
Read the Checklist at Part 17 to see what you can use as proof.
5
Part 4 About rent
Do you own your own home or
Answer the next question.
No
have a mortgage?
Yes Go to Part 6.
Are you a council tenant?
Answer the questions below.
No
Go to Part 5.
Yes
When did you start renting your
/ /
home?
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.
How long is the tenancy for?
/ / / /
to
Please tick to show if the
property is let as:
furnished
partly furnished
minimally furnished
unfurnished
How much rent are you
Ł every
charged?
(week/2 weeks/4 weeks/month)
Does anyone else share the rent
No
with you and your partner?
Yes
Tell us their names.
Has your rent changed
No
in the last 12 months?
Yes
Send us proof of the date it changed, and by how much it changed.
When is the next rent increase
/ /
due?
Has your rent been registered as
No
a fair rent by the rent officer?
Yes Please send us the notice of registration form R05.
6
Part 4 About rent - continued
Do you have any weeks when
No
you do not have to pay rent?
Yes
How many?
Are you behind with your rent?
No
Yes
By how much?
Ł
By how many weeks?
Who pays the Council Tax
on your home?
Please tick the appropriate box.
You and your partner
Your landlord
Someone else
Tell us who pays the Council Tax.
Do you pay water charges
No
direct to the water authority?
Yes
Are you living away from this
No
address at the moment?
Yes
Tell us why you are not living there.
When did you last live there?
/ /
When do you expect to go back there?
/ /
Tell us the address of where you are living at the moment.
Postcode
If your home has been sublet, tell us who lives there now.
7
Part 4 About rent - continued
Does your rent include
No
money for the following?
Meals
Ł
Yes
How much?
Which meals
are included?
Heating
No
Ł
Yes
How much?
Lighting
No
Ł
Yes
How much?
Hot water
No
Ł
Yes
How much?
Fuel for cooking
No
Ł
Yes
How much?
Laundry
No
Ł
Yes
How much?
General counselling
No
and support
Ł
Yes
How much?
Emergency alarm
No
Ł
Yes
How much?
Room and window cleaning
No
Ł
Yes
How much?
Central heating
No
Ł
Yes
How much?
Internal decoration
No
Ł
Yes
How much?
Gardening
No
Ł
Yes
How much?
Garage or parking space
No
Yes
No
If  Yes , do you have to rent the garage
or parking space as part of your tenancy
agreement?
Yes
8
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.
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.
Postcode
Are you, your partner or
No
children related to your landlord
or agent, or to your landlord s
Yes What is the relationship?
partner or your agent s partner?
Related includes related through
marriage, even if the marriage has
ended.
What sort of building do
Detached house Flat in house Hotel
you live in?
Semi-detached
Board and lodgings
Flat in block
house
Caravan, mobile
Terraced house Flat over shop
home or houseboat
Residential nursing
Maisonette Bedsits or rooms
home
Residential care
Bungalow Hostel
home
Other
How many floors are there?
Do you and your household
No
occupy only part of the building
you have listed above?
Yes
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
Which floors do you live on?
For example, ground floor, first floor
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.
9
Part 5 About where you live
In the whole Just for you and That you share with
How many rooms are there
building? your household? other people?
in the building?
Living rooms
Bedsitting rooms
Bedrooms
Bathrooms
Toilets
Kitchens
Other rooms
Do you use your
No
home for business?
Yes
Please tell us if you have any
special needs that require you
to rent a home of this size
Do you or your partner have a
No
carer that stays overnight?
Yes
If Yes
Do they have their own
No
bedroom?
Yes
Who do they provide care for?
Why is the care required?
How often does the carer stay?
10
Part 5 About where you live - continued
Do you have a main home
No
somewhere else?
If your main home is
somewhere else in the UK or
Yes
What is the address?
abroad, tick  Yes , even if you do
not pay rent on it.
Postcode
How much do you pay for this home?
Ł
Part 6 About Income Support, income-based
Jobseeker s Allowance, income related
Employment and Support Allowance and
Pension Credit
Are you or your partner
No
Go to Part 7.
getting or waiting to hear about
a claim for Income Support,
Yes
income-based Jobseeker s Answer both the questions in this part, then go to Part 7.
Allowance, income related
Employment and Support
Allowance or Pension Credit?
You Your partner
Are you or your partner
No No
getting Income Support,
income-based Jobseeker s
When did you start When did they start
Yes Yes
Allowance, income related getting it? getting it?
Employment and Support
/ / / /
Allowance or Pension Credit?
Are you or your partner still
No No
waiting to hear about a claim
for Income Support, income-
When did you When did they
Yes Yes
based Jobseeker s Allowance, claim? claim?
income related Employment and
/ / / /
Support Allowance or Pension
Credit?
11
Part 7 About being self-employed
Are you or your partner
No Go to Part 8.
self-employed?
Yes
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 you or your partner
No
a company director?
Yes
You Your partner
What kind of work do you do?
When did the business start? / / / /
What is the business address?
Postcode Postcode
Are there any other partners
No No
in the business?
Tell us their name Tell us their name
Yes Yes
and address. and address.
Postcode Postcode
How many hours a week
do you work?
Do you get a Business
No No
Start-up Allowance?
Yes Yes
How much? How much?
Ł Ł
How often? How often?
Every Every
Do you pay into a private
No No
pension scheme?
Yes Yes
How much? How much?
Ł Ł
How often? How often?
Every 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.
12
Part 8 About working for an employer
Do you or your partner work for
No Go to Part 9.
an employer?
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
Yes
form.
If you are sending a separate sheet of paper, tick this box.
You Your partner
What kind of work do you do?
What is your employer s
name and address?
Postcode Postcode
When did you start this job? / / / /
Are you employed for a
No No
limited period?
When will you When will they
Yes Yes
finish? finish?
/ / / /
How often do you get paid?
Every Every
How much do you get paid?
ŁŁ
How are wages paid i.e. Bank
account?
When was your last pay rise?
/ / / /
When will your next pay rise be?
/ / / /
How many hours a week
do you usually work?
Are you getting Statutory Sick
No No
Pay (SSP) or Statutory Maternity
Pay (SMP) from your employer
Yes Yes
at the moment?
If Yes, when did this start? / / / /
Are you getting any other sick
No No
pay or maternity pay from your
employer at the moment?
Yes Yes
Do you pay into a private or
No No
company pension scheme?
Yes Yes
How much? How much?
ŁŁ
Every 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.
If you get tips or bonuses, tell us about these in Part 15.
13
Part 9 About any other work
Do you or your partner do any
No Go to Part 10.
other work at all?
This could be voluntary work or
any other work, even if it is not
Yes Answer the questions on this page.
paid work.
You Your partner
What kind of work do you do?
What is the name and address
of the person you do this work
for?
Postcode Postcode
When did you start this work? / / / /
How many hours a week
do you work?
Do you get paid?
No No
If you only get expenses or tips,
still tick  Yes and give details.
Yes Yes
How much? How much?
ŁŁ
Every Every
When will your next pay rise be?
/ / / /
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.
14
Part 10 About benefits and pensions
" Pension Credit
" Attendance Allowance
Are you or your partner getting
" Retirement Pension
" Adoption Pay
any benefits or waiting to hear
" Severe Disablement Allowance
" Bereavement Allowance
about benefits you have
" Statutory Maternity Pay
" Carer s Allowance
claimed?
" Statutory Paternity Pay
" Child Benefit
Read the list of benefits and tell us
" War Disablement Benefit, War Pension
" Disability Living Allowance
about any you or your partner are
or War Widow s Pension
" Disabled Person s Tax Credit
getting now or have claimed.
" Widow s or Widower s Benefits
" Fostering Allowance
" Working Tax Credit
" Guardian s Allowance
" Children s Tax Credit
" Incapacity Benefit
" Statutory Sick Pay
" Industrial Injuries Disablement Benefit
" Any other social security benefit
" Industrial Death Benefit
" Contribution-based Jobseeker s Allowance
" Maternity Allowance
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.
No Go to Part 11.
Tell us about the
Yes
benefits below.
If you are sending a separate sheet of paper, tick this box.
You Your partner
The name of the benefit or
pension
Waiting to hear
Getting now
How much? How much?
Ł Ł
How often and by what method? How often and by what method?
Every by Every by
The name of the benefit or
pension
Waiting to hear
Getting now
How much? How much?
Ł Ł
How often and by what method? How often and by what method?
Every by Every by
The name of the benefit or
pension
Waiting to hear
Getting now
How much? How much?
Ł Ł
How often and by what method? How often and by what method?
Every by Every by
We need to see proof. We need to see proof.
15
Part 11 About other money coming in
This includes occupational pensions, student income such as grants,
Do you or your partner, or any
loans or bursaries, maintenance or child support for you, your partner or
children you are claiming for,
any of the children you have told us about on this form; and any cash
have any money coming in that
payments. Also tell us about any money you get from people living in
you have not already told us
your house as boarders, lodgers or subtenants. You do not need to tell us
about on this form?
about payments from the Independent Living Fund, the Eileen Trust or the
MacFarlane Trust.
No Go to Part 12.
Answer the questions
Yes
on this page.
Other money 1
What is the money for?
Who gets it?
How much do they get?
Ł
How often?
Every
Other money 2
What is the money for?
Who gets it?
How much do they get?
Ł
How often?
Every
Other money 3
What is the money for?
Who gets it?
How much do they get?
Ł
How often?
Every
Does anyone owe money to
No
you, your partner, or any
children you are claiming for?
Yes
What for?
How much?
Ł
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.
16
Part 12 About bank accounts, savings, investments and
property
Do you or your partner have
any savings, investments or own
No Go to Part 13.
or partly own any land or
property other than the home
Yes
Answer all the questions in this part. We must see proof
you live in? of all the capital, savings and investments. Read the
checklist at Part 17 to see what you can use as proof.
This includes current accounts and
savings accounts with a bank or
building society, post office
accounts, Premium Bonds or stocks
and shares.
Do you or your partner have
No
any bank accounts?
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.
If you are sending a separate sheet of paper, tick this box.
Name of bank Account number
Whose name is the account in? How much is in the account?
Ł
Name of bank Account number
Whose name is the account in? How much is in the account?
Ł
Do you or your partner have
No
any building society accounts?
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.
If you are sending a separate sheet of paper, tick this box.
Name of building society Account number
Whose name is the account in? How much is in the account?
Ł
Name of building society Account number
Whose name is the account in? How much is in the account?
Ł
We need proof of all your accounts, even those with little or no money,
or this may delay paying your benefit.
17
Part 12 About bank accounts, savings, investments and
property
Do you or your partner have
No
any post office accounts?
This includes savings accounts and
Yes
Tell us about post office accounts. If there are more than
Girobank accounts.
2 post office accounts, tell us about the others on a separate
piece of paper and send it with this form.
If you are sending a separate sheet of paper, tick this box.
Type of account Account number
Whose name is the account in? How much is in the account?
Ł
Type of account Account number
Whose name is the account in? How much is in the account?
Ł
Do you or your partner have
No
any Premium Bonds?
Yes
Value
Ł
Do you or your partner have
No
any National Savings
Certificates?
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.
If you are sending a separate sheet of paper, tick this box.
Issue number Value How many?
Ł
Issue number Value How many?
Ł
Do you or your partner have
No
any stocks, shares, bonds or unit
trusts?
Yes
Company name
How many?
Approximate value
Ł
Company name
How many?
Approximate value
Ł
We need proof of all your accounts, even those with little or no money,
or this may delay paying your benefit.
18
Part 12 About bank accounts, savings, investments and
property
Do you or your partner have
any other capital, savings or
No
investments?
Tell us about any TESSAs or ISAs
Yes
Tell us about this.
here.
Type of account Account number
Whose name is the account in? How much is in the account?
Ł
Do you, your partner have any
Type of account Account number
other savings or investments?
Whose name is the account in? How much is in the account?
Ł
Do any of your or your partner s
savings or investments include:
No
" money from the sale of a house, or
" money from a charity?
Yes
We will write to you about it.
Apart from your home, do you
or your partner own any other
No
property or land in this country
or abroad?
Yes
We will write to you about it.
If it is on a mortgage or a loan,
still tick Yes.
Have you or your partner
received:
No
" a Far Eastern Prisoner of War
Compensation payment, or
Yes
What payment did you receive? Who received the payment?
" a compensation payment made to
A Far Eastern Prisoner of War
victims of atrocities that happened
Compensation payment You Your partner
during the Second World War?
We need to know this to make A compensation payment made
to victims of atrocities that
sure we do not count it as part of
happened during the
your savings.
Second World War You Your partner
Have you or your partner
received a payment from the
No
CJD (Creutzfeldt-Jakob Disease)
Trust?
Yes
We will write to you about it.
19
Part 13 How you will be paid
How do you want us to pay Payments direct into a bank or building society account is the safest way to
your Housing Benefit? pay your Housing Benefit.
We can pay your Housing Benefit
straight into your bank or building
" If you are a tenant of a private landlord, your Housing Benefit will be
society account or in certain cases
paid to you.
straight to your landlord.
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
Tell us the following details.
account.
Name of bank or building
society
Address
Postcode
Whose name is the account in?
Account number
Sort code
Please make sure this account is included in Part 12 of this form.
I want my benefit to go straight
Private tenants cannot choose to have payments made to their
to my landlord.
landlords.
20
Part 14 Sharing information
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 Landlord s name
Full name (IN CAPITAL LETTERS) Address
Address
Tel No:
Representative s name and organisation
Address
Tel No:
21
Part 15 Anything else you need to tell us
Use this box to tell us anything
If you are sending a separate sheet of paper, tick this box.
else you think we should know
about. Use a separate sheet and
attach it to this form if you need
to.
Part 16 Backdating
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.
Why have you not claimed
before?
Date you want to claim
/ /
benefit from
During this earlier period, were
your circumstances different to No
those you have told us about on
this form? Yes
Please tell us about it below
What has changed?
We need proof of changes in your
circumstances for this period.
If you need more space, send a separate sheet of paper
and tick this box.
22
Part 17 Checklist
Proof of identity
Please tick to tell us what proof you
We need to see at least two of these documents for each person, and one of the
are sending with this form. We
documents must show the National Insurance number.
must see original documents, not
Such as a:
copies.
" birth certificate;
" marriage certificate;
If you do not provide all the proof
" passport;
we need, we might not be able to
" National Insurance number card;
pay you any benefit. We need the
" medical card;
same proof for your partner, if you
" driving licence;
have one, and for any other adults
" UK residence permit;
living in your home.
" EEC identity card; or
" recent gas or electricity bill.
If you cannot send the proof we
We need to see at least 2 of these documents for each person.
need at the moment, send the form
back to us now and send the proof
Proof of bank accounts, savings, investments and property
later. We can start to process your
This means:
claim, but we will not be able to
" all your bank, building society or post office books,
pay you any benefit until we have
or certificates for Premium Bonds;
all the proof.
" your bank statements, showing details for the last 2 months, printouts from
internet banking are acceptable;
Please do not send valuable items
" National Savings Certificates; or
through the post. If you can, bring
" ISAs, stocks, shares and unit trusts.
them into one of our reception
We need to see proof on any interest or dividends you get on investments
areas. The address is on the second
and savings.
page of the information sheets that
are attached to the front of this
Proof of earnings
form. We will take the details we
This means your last 5 payslips if you are paid every week, your last 3 payslips
need and give you the documents
if you are paid every 2 weeks, or your last 2 payslips if you are paid every
back straight away. If you cannot
month. If you do not have these payslips, ask your employer to fill in the
get into the office, phone us for
Certificate of earned income on page 25. If you or your partner are
more advice.
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.
23
Part 18 Declaration
Even if someone else has filled
Please read this declaration carefully before you sign and date it.
in this form for you, you must
" I understand that this claim is made to you, Cardiff County Council.
sign this declaration if you can.
" I declare that the information I have given on this form is correct and
If you have a partner, getting
complete as far as I know and believe.
them to sign this form should
" I understand that if I knowingly give information that is incorrect or
allow us to process your claim
incomplete, I may be liable to prosecution or other action.
more quickly, but they do not
" I agree that you will use the information I have provided to process my
have to sign.
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.
Signature of person claiming
Date
/ /
Partner s signature
Date
/ /
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.
Name of the person who
filled in the form.
Signature of the person
Relationship to the
person claiming
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: [phone]. Fax: [phone]
Email: [e-mail]
24
Questionnaire
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.
Nationality
No Yes
Do you consider yourself to be
Welsh?
White Black
Ethnic Origin
Which background do you
British African
feel you belong to?
Irish African Somali
European British
Other white Caribbean
background
please specify Other black
background
please specify
Asian Mixed Ethnic Background
Bangladeshi White and Asian
British White and Black African
Indian White and Black Caribbean
Pakistani Other mixed ethnic
background
Sri Lankan please specify
Other Asian
background
please specify
Other Groups
Arab Yemeni
British Chinese Other background
please specify
Chinese
Czech
Any Other Ethnic
Gypsy Traveller
Background
Japanese
Any other ethnic
background
Korean
please specify
Polish
Somali
25
26
Cardiff County Council
Housing Benefit/Council Tax Benefit/Council Tax
Reduction Certificate of earned income
Please give this form to your employer to complete
We may contact your employer direct if we have a query with the information provided
Employee details (person claiming benefit)
Employee s name
Employee s address
including postcode
Employee s number
Occupation
Telephone Number
Employer details (who you work for)
Name Employer s
authorisation stamp
or attach a letterhead
Position
Business Name and
address Telephone Number
Income details
Date employment Normal hours per week
/ /
started
Date employment
How are they
by cash
/ /
Ended (if applicable)
paid?
by cheque
Tax Code
into a bank account
National Insurance
Number
other (please detail)
Ł per
Normal basic pay
Date of last pay
How often are
every week
/ /
increase
they paid?
Date of next
every two weeks
/ /
expected increase
every four weeks
Do they currently
Yes
get sick pay or
every month
maternity pay?
No
other (please detail)
If  Yes , what do
they receive, when
from, and when is
it due to expire?
27
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.
Payment 1 Payment 2 Payment 3 Payment 4 Payment 5
Pay period starting
/ / / / / / / / / /
Pay period ending
/ / / / / / / / / /
Number of hours worked
Payments
Year To Date
Gross Earnings
ŁŁŁ ŁŁŁ
Sick Pay
ŁŁŁ ŁŁŁ
Overtime
ŁŁŁ ŁŁŁ
Maternity Pay
ŁŁŁ ŁŁŁ
Other payments
ŁŁŁ ŁŁŁ
(please detail)
Deductions
Year To Date
Tax
ŁŁŁ ŁŁ Ł
National Insurance
ŁŁŁ ŁŁ Ł
Pension
ŁŁŁ ŁŁ
Net Payment ŁŁŁ ŁŁ
Do your employees
Yes No
earnings vary a lot?
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.
Pension
Hours Gross National
Period start Period end Tax
Contributions
worked Payments Insurance
/ / / /
ŁŁŁŁ
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 Yes
Is your employee
been worked since expected to earn any
No
starting work? additional money on top
of their normal wages?
If  No what hours are
eg. bonus,
they currently working
regular overtime, etc.
and when will they start
If so please provide
normal hours?
details
Declaration What to do now
The information I have given the Council is true and complete
Cardiff County Council
Signature Please post this form to:
Benefits Section
Freepost CF429
Date
PO Box 60000
/ /
CF11 0WZ
Private and Confidential
28
Cardiff County Council
Proof of rent form
(For your landlord or agent to fill in)
Landlord and tenancy details - continued
Tenant details
Is the tenant behind
No
I would be grateful if you could help your tenant
with their rent?
by filling in this form and returning it to me.
Yes By how much?
Tenant s name
Ł
By how many weeks?
Address and
postcode
Services
Ł Ł
Meals Gardening
Does your rent
include money for
Ł Ł
Landlord and tenancy details Heating Water rates
any of the following?
Landlord s details Ł Ł
Lighting Hot water
Name
Ł
Emergency alarm
Address and
Ł
Fuel for cooking
postcode
Ł
Room and window cleaning
Ł
General counselling and support
Please tell us about your agent
Agent s details
Other
if you have one.
Ł Ł
Laundry
Please
specify
Name
Ł
Central heating
Address and
Ł
Internal decorating
postcode
Ł
Garage or parking space
As far as I know, the information I have
Declaration
Tenancy details
given is correct. I will write to you
Is this a tenancy
No
immediately if I know that my tenant s
where the agent only
circumstances have changed.
Yes
acted for a finding fee?
Signature
Are you related to
No
the tenant, their
Yes Relationship
partner or their
Date
children?
/ /
Date the tenant
/ /
I will accept Housing Benefit for this tenant.
Declaration for
moved in
If you pay me too much, I understand you
direct payments
Date the tenancy
/ /
may ask me to pay it back and take me to
started
court if I don t. I will write to you
How much rent do
immediately if I know that my tenant s
Ł
you charge? circumstances have changed.
Signature
Is there a joint No
tenancy?
Yes Number of tenants
Date
How much rent do
/ /
Ł
you charge for each
tenant if it is a joint
What to do now
Cardiff County Council
tenancy?
Please post this
Benefits Section
How often is the
form to:
Freepost CF429
rent due?
PO Box 6000
(weekly/2 weekly/4 weekly/monthly)
Cardiff
Has the rent officer
No
CF11 0WZ.
registered a fair
Please sent us the notice of
rent?
Yes registration form R05. Private and confidential
29
30
Cardiff County Council
Housing Benefit/Council Tax Benefit/Council Tax Reduction
Change of Circumstances Form
Please keep this form and return it to The Benefits Section with details of any
changes in your circumstances.
Name
Address
Postcode:
Telephone Number
Claim Reference:
Date of Change
/ /
Details of the change
(continue on a separate sheet
if necessary)
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.
Signature
Date
/ /
If you are not the claimant
please complete this section:
Name
Relationship to claimant /
organisation
Telephone Number
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.
31
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 Ł6000 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.
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32
Version 9 March 2013