Argyll and Bute Council

Benefits

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. Please fill in all the information below.

SECTION 1 – PERSONAL DETAILS


Your Full Name:
Address:
Benefit Reference/Claim Number:

I wish to apply for extra help towards my rent

I wish to apply for extra help towards my Council Tax

(note: all sections should be completed if either or both of these boxes have been ticked

I wish to apply for extra help towards a Rent Deposit/

Rent in Advance for my new address (please supply a

copy of your tenancy agreement as proof)

Property Address Details______

______

Start Date of New Tenancy ______

Date of Intention to Move in ______

Please go to Section 4 and sign declaration if you wish only to be considered for a rent deposit/rent in advance payment

SECTION 2 – REASONS FOR APPLYING FOR DISCRETIONARY PAYMENTS

  1. Why do you wish to apply for Discretionary HousingPayment?

2. Why did you move to this address?
3. What, if anything, makes this address, especially suitable for you?
  1. Please tell me 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 me 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?
  1. If you have any other circumstances you would like us to take into account please tell us.

SECTION 3 – INCOME/EXPENDITURE

Has your income changed since you applied for Housing and / or Council Tax
Benefit?
Yes No
If yes please tell us what income has changed and the date(s) the changetook place. Please also provide us with evidence of the change.
______
______
Please detail below a list of all your expenditure.
Type of Expenditure How Often £
______
______
______
______
______
______
______
______
______
______

SECTION 4 - DECLARATION

Please read this carefully before you sign the form.
  • I declare that the information I have given on this form is correct and complete to the best of my knowledge.
  • If the information I have given changes at anytime I will inform Argyll & Bute Council immediately.
  • I understand that if the information I have given is incorrect I may be prosecuted.
  • I authorise Argyll & Bute Council to make enquiries to confirm the information I have given unless I have indicated otherwise.
  • I authorise Argyll & Bute Council to cross check the information I have given with the other sections of the Council within the terms of the Data Protection Act 1998

Signatures

Claimant’s Signature ______Date ____ / ____ / ____
Partner’s Signature ______Date ____ / ____ / ____

Please return this form to:

Argyll & Bute Council

Customer & Support Services

Witchburn Road

Campbeltown

PA28 6JU

For office use
Decision If Yes: Amount awarded £ Date from ___ / ___ / ___
If No: Reason ______
______
Signature ______Date ___ / ___ / ___