New Preliminary Means Test Form

PRELIMINARY TEST OF RESOURCES FOR OWNER OCCUPIERS AND PRIVATE TENANTS – DISABLED FACILITIES GRANT

The following Test of Resources is intended to provide an early indication of the amount you will be required to contribute (if any) towards the cost of carrying out grant aided works to your property. This will avoid causing undue delay in cases where your contribution would cover the full cost of the works and no grant would be payable. As soon as an assessment has been completed, based on the information provided, you will be notified of your likely contribution. Your completed form should be returned to the LONDON BOROUGH OF HAVERING, GRANTS TEAM, 5TH FLOOR, MERCURY HOUSE, MERCURYGARDENS, ROMFORD ESSEX RM1 3SL

If youwould like any advice on completing this form then please telephone a member of the Grants Team on 01708 434070 or 01708 434071 and they will be happy to help you.

PLEASE READ THE NOTES ON THE LAST PAGE IN CONJUNCTION WITH THIS QUESTIONNAIRE.

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Please answer each question in turn unless directed elsewhere. This section is to be completed in respect of the disabled occupant (and their partner).

You and Your Family

What is the address if the property …………………………………

where works are due to be carried out?…………………………………

2.Are you an owner or a tenant ofOwner/Tenant

the dwelling (delete as appropriate)

3.Please give your full name: ………………………………….

4.Please give your date of birth / /19 age ……………….

5.Have you a partner living with you?Yes No (go to Q.7 )

Please give the following details

in respect of your partner:

Partner’s full name:…………………………………..

Date of birth: / /19 age………………...

Are you or is your partnerYou YES/NO

Registered blind?Your Partner YES/NO

Are you or your partner unable to You YES/NO

work because of sickness, and haveYour Partner YES/NO

been so for at least the last 28 weeks?

If you have answered “YES” to question ……………………………..

8 please provide details, including dates: …………………………….. …………………………….

Are you or is your partner providedYou YES/NO

with an invalid carriage or other vehicle,Your Partner YES/NO

or in receipt of an allowance in respect

of such a vehicle (including via the

Mobility Scheme)?

If yes, please give details ………………………………………………

Are you or our partner in receipt of any

of the following benefits in respect of

illness or disability? You Your Partner

Yes No Yes No

Attendance Allowance

Mobility Supplement

Invalidity Pension

Severe Disablement Allowance

Invalid Care Allowance

Disability Living Allowance

Disability Working Allowance

If you or your partner receive the

care component of disability livingHighest Middle Lowest

allowance, what rate is the care

component awarded at?

You

Your Partner

If you or your partner do not receive You Your Partner

Attendance Allowance or the care Yes No Yes No

Component of disability living allowance

At the highest or middle rate, is this

Because you are undergoing treatment?

Is anyone in receipt of an Invalid CareYES/NO

allowance in respect of caring for you

or your partner?

If you have answered “yes” please give…………………………..

Details, including the name of the person…………………………..

Who receives the allowance, and whether …………………………..

It is paid in respect of the care of yourself…………………………..

Or your partner:

Do you or your partner have any dependant YES NO (go to

Children under the age of 19, living with you? Q.22)

Please give the details requested below in respect of each of these children.

Full Name Date ofWhat do they do are they registered

Birtheg. school, student, blind or in receipt of

work etc. attendance allowance

or disability allowance

…………….. ……….. ………………….. ………………………..

…………….. …..……………………….. ………………………..

…………….. ………..………………….. ………………………..

Do any of them work 16 hoursYes No (go to Q.17)

per week or more?

If yes, please give details

Nametype of workGross PayHow often paid

………………..………………£……………………………

Do any of them have any otherYes No (go to Q.18) income whatsoever?

If yes, please give details

Nametype of incomehow muchhow often paid

……………….……………….£………………………….

Do any of them have any savingsYes No (go to Q.19)

or other investments?

If yes, please give details

NametypeCurrent Value

……………..………………£……………..

Do any of them own any land, Yes No (go to Q.20)

Property, business or have any

Other capital whatsoever?

If yes, please give details

Name ……………………Details………………………..Value £……….

Name ……………………Details ……………………….Value £……….

Is there anyone aged 18 or over whoYesNo

lives with you, apart from your partner

or dependent children?

If yes, please give details

Name …………………………Relationship to you ………………….

Do any of them receive Attendance

Allowance or the care componentYes No

Of Disability Living Allowance at the

highest or middle rate?

If yes, please give details, including the ………………………….

name of the person who receives the………………………….

allowance.………………………….

Your Income

22.Are you or your partner entitled to and receiving any of the following benefits?

Yes No

Income Support

Income-based Jobseeker’s Allowance

Guarantee Pension Credit

Housing Benefit

Council Tax Benefit

If you have answered “Yes” to any of the above, go directly to the

declaration at the end of this section. If no, please complete all

questions in this section.

23.Are you or your partner currently inYes (go to Q.24)

paid employment?

No (go to Q.27)

24. please give the following details for each:

you your partner

name & address of employer …………….. …………….. …………….. ……………..

…………….. ……………..

Occupation/job title …………….. ……………..

Gross pay …………….. ……………..

How often paid …………….. ……………..

Income tax paid …………….. ……………..

National insurance contributions …………….. ……………..

Occupation or private pension

Contributions …………….. ……………..

Average hours worked per week

(if less than 16 hours) …………….. …………….

25. do you or your partner have any other

paid employment (eg second or part Yes No (go to Q.27)

time job(s)?

26.Please give details for each job:

YouYour partner

Name & address of employer:……………….………………..

……………….……………….. ………………. ……………….. Occupation/Job Title: ………………. ………………..

Gross Pay:……………….………………..

How often paid……………….………………..

National insurance contributions……………….………………..

Private pension plan payments……………….……………….. Average hours worked per week

(if less than 16 hours)……………….…………………

27.Are you or your partner self employed? Yes No (go to Q.29)

Please give full details of self-employment:

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

average annual gross income from

self employment: £……………………

Are you or your partner in receipt of a

Pension of any kind? Yes No (go to Q.31)

please give details of the pension(s) you or your partner receive:

YouYour Partner

State retirement pension£………per……£………per……..

Occupational pension£………per…...£………per……..

Widow’s pension£………per.…..£………per……..

War widow’s pension£………per.…..£………per……..

War disablement pension£………per.…..£………per……..

Any other pension(s)£………per.…..£………per……..

£………per.…..£………per……..

Are you or your partner in receipt of

any state benefits?Yes No (go to Q.33)

32.Please give details of the benefits you or your partner receive, including any of the following:

YouYour Partner

Job-Seeker’s allowance £……… per……..£……… per……..

Statutory maternity pay £………. per……..£……… per……..

Statutory sick pay £………. per……..£……… per……..

Sickness benefit £………. per……..£……… per……..

Family tax credit £………. per……..£……… per……..

Child benefit £………. per……..£……… per……..

One parent benefit £………. per……..£……… per……..

Incapacity benefit £………. per……..£……… per……..

Severe disablement allowance £………. per……..£……… per……..

Invalid care allowance £………. per……..£……… per……..

Disability working allowance £………. per……..£……… per……..

Housing Benefit £………..per……..£……….per……..

Council Tax Benefit £………..per……..£……….per……..

Any other benefit(s) £………. per……..£……… per……..

£………. per……..£……… per……..

do you or your partner receive any

other income whatsoever?Yes No (go to Q.35)

please give details of this income,

including any of the following:

YouYour Partner

Government training allowance £……… per……..£……… per……..

Student Grant £………. per……..£……… per……..

Student Loan £………. per……..£……… per……..

Other scholarship or bursaries etc £………. per……..£……… per……..

Parent’s contribution to

student loan £………. per……..£……… per……..

Adoption allowance £………. per……..£……… per……..

Maintenance from former partner £………. per……..£……… per……..

Annuities £………. per……..£……… per……..

Charitable income and voluntary

payments £………. per……..£……… per……..

Income from tenants, sub tenants,

boarders or lodgers £………. per……..£……… per……..

Any other income £………. per……..£……… per……..

£………. per……..£……… per……..

Your Savings, Investments and Other Capital

do you or your partner have any cash,

savings or other investments?Yes (please complete

details overleaf)

No (go to Q.37)

Please give details of savings or other investments, including the

following:

YouYour Partner

Cash savings£………………£………………

Bank current account£………………£………………

Bank deposit account£………………£………………

Bank other account(s)£………………£………………

£………………£………………

post office ordinary account£………………£………………

post office investment account£………………£………………

building society account(s)£………………£………………

£………………£………………

premium bonds£………………£………………

national savings certificates£………………£………………

issue no………issue no………

date…………...date…………..

no. held……….no. held………

Stocks, shares, unit trusts etc.

Details…………………………………...

Current values (£)……………………………………

Details……………………………………

Current values (£)……………………………………

Any other investments

Details……………………………………

Current value (£)……………………………………

Details……………………………………

Current value (£)……………………………………

Please give details of any one-off………………………….

payments you or your partner have………………………….

received over the last 12 months………………………….

including the dates of such payments………………………….

do you or your partner own any land,

property, business or have any other

capital whatsoever?Yes No (go to Q.40)

please give details of capital including……………………………..

the current value(s) where known:……………………………..

……………………………..

do you or your partner make a

contribution in respect of a studentYes No (go to the grant for a son or daughter or partner? Declaration)

41.please provide details of contributions:…………………………………..

…………………………………..

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DECLARATION

WARNING: IF YOU KNOWINGLY MAKE A FALSE STATEMENT YOU MAY BE LIABLE TO PROSECUTION

I declare that to the best of my knowledge, information and belief the information provided on this form is correct.

Date …………………….Signature ………………………….

Please provide a contact telephone number (home) …………………….

(work) …………………….

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NOTES

In question 24, if you have a partner and are paid jointly, as a couple, enter the details in one or other column (it does not matter which) but not both. You may need to provide evidence of earnings covering the last 52 weeks in respect of any paid employment, together with details of any private pension plan payments made in the same period.

In questions 24 & 26, Gross pay should include bonus or commission, overtime, holiday pay, sick pay or maternity pay.

In question 27, it will help if you supply a copy of your latest accounts which gives details of your self-employment. Please include details of any pension plan payments, income tax and national insurance contributions paid.

In question 30, give the net amount if your pension is taxed.

In question 5, for this purpose, a person lives with you if they share with you a room or rooms other than bathroom, lavatory or communal area, eg Hall, but not if you each pay separately for your accommodation to a landlord.

In question 32, you do not need to include any of the following:

Attendance AllowanceCouncil Tax Benefit

Disability Living AllowanceGuardian’s Allowance

Income SupportHousing Benefit

Payments from the Macfarlane Trusts or the Independent Living Fund

Payments from the fund i.e. money made available by the Secretary of State under a scheme set up on 24 April 1992.

Payments to compensate for the loss of entitlement to benefit where you did not become entitled to Income Support for a period beginning 11 April 1988.

Payments under the “business on own account” scheme, the “personal reader service” or the “fares to work” scheme.

Social fund payments under Part VIII of the Social Security Contributions and Benefits Act 1992.

Certain other benefits and allowance may also be disregarded in the calculation of your income, but for the purpose of completing this form you should only exclude those payments mentioned above. If you are in any doubt about whether a payment falls into one of these categories you should include it and provide full details of the nature of the payment so that the Council can decide whether or not it can be disregarded.

Cash savings, money in the bank, building society or post office accounts, national savings certificates, premium bonds, stocks, shares and unit trusts.

If you have a partner and hold any savings or other capital jointly, enter the details in one or other column (it does not matter which), but not both.

You may need to provide evidence of all savings, investments and other capital.

In question 37, you may need to provide evidence of all other income received in the last 52 weeks.