South Ayrshire Council

Corporate Services – Benefit Services

County Buildings, Wellington Square, Ayr, KA7 1DR

Discretionary Housing Payments

As you have indicated that you are interested in applying for

Discretionary Housing Payment, I require certain information from

you in order that I may consider your claim

General Details

Your name: / Partner’s name:
Address:
Benefit reference no:

I wish to apply for extra help towards my rent

I wish to apply for extra help towards my Council tax

Reason for Applying for Discretionary Housing Payment

(Please answer all questions that are relevant to your claim, giving as much detail as possible)

1. Why do you wish to apply for Discretionary Housing Payment?
2. Why did you move to this address?
3. What, if anything, makes this address especially suitable for you?
4. Please tell us about any health problems that you or any member of your family might have.
* If you, or a member of your family, are receiving treatment, it would help if we had a letter from your doctor to confirm this.
5. Have you tried to agree a lower rent with your landlord? / Yes
No
If you have tried to agree a lower rent, tell us what happened.
* If your landlord has agreed a lower rent, I will need to see a new lease or a letter from your landlord.
6. Do you have any relatives or friends who could help you?
7. If you have any other circumstances you would like us to take into account, please tell us.

Financial Details

Please provide all details of your weekly income and outgoings by completing the attached proforma, which should be returned with this application form.

Our Address

Please return your form to: South Ayrshire Council.

You can hand the form in to our Benefits staff, who are located at the local Area Offices.

For office use

Decision:
If Yes: / Amount awarded / £ / Date from:
If No: / Reason
Signature: / Date:


Declaration

(Please read this declaration carefully before you sign and date it)

I/ we declare that the information I/ we have given on this form is correct and complete to the best of my/ our knowledge.
I/ we authorise the Council to make any necessary enquiries to verify the information on this form.
I/ we understand that, if I/ we give information that is incorrect or incomplete, or fail to report any changes which might affect my/ our benefit, I/ we may be prosecuted.
I/ we authorise the Council to cross-check the information I/ we have given with other sections within the Council, Rent Officer, other Councils and benefit authorities.
I/ we understand that, if my/ our circumstances change at any time, I/ we must notify the Council immediately.
Signature of person claiming:
Signature of partner:
Date:
Forms filled in by someone other than the person claiming:
Please tell us why you are filling in this form for someone else
Name of person who filled in the form:
Signature of the person:
Relationship to the person claiming:

Remember that failure to provide any of the evidence requested on this form will result in the authority being unable to pay you any benefit.

South Ayrshire Council is registered under the Data Protection Act 1998. The information collected on this form, and from supporting evidence, by South Ayrshire Council will be used to process your housing benefit and Council tax benefit claims. The information may be passed to the Department of Social Security, Employment Service and Inland Revenue, as permitted by law.
We may check information provided by you, or information about you provided by a third party, with other information held by us. We may also get information from certain third parties, or give information to them to check the accuracy of information, to prevent or detect crime, or to protect public funds in other ways, as permitted by law. These third parties include government departments and local authorities.
We will not disclose information about you to anyone outside South Ayrshire Council, nor use information about you for other purposes unless the law permits us to.

South Ayrshire Council

Corporate Services – Benefit Services

Discretionary Housing Payments

Analysis of Financial Details

Outgoings (weekly) / £ / Income (weekly) / £
Rent / Applicant (net)
Council tax / Partner (net)
Mortgage / Jobseekers’ allowance
Second mortgage / Employment and Support Allowance
Electricity / Income support
Gas / Working Tax Credit
Other Fuel / Child Tax Credit
Life insurance / Child benefit
Buildings insurance / Disability Living Allowance (Care)
House contents insurance / Disability Living Allowance (Mobility)
TV rental / Incapacity benefit
TV licence / Pension (state)
Housekeeping / Pension (works)
Maintenance / Widow’s pension
Fines / Statutory Sick Pay
Telephone / Statutory Maternity Pay
Clothing / Maintenance
Travel / Contributions
Childminding / Other (please specify)
School meals
Regular prescriptions
Pet food
Cigarettes
Pocket money, clubs
Nursery
Other (please specify)
Total outgoings / Total income
Balance (weekly)
Balance (monthly)

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