For Universal Credit Customers

DISCRETIONARY HOUSING PAYMENTS

FOR UNIVERSAL CREDIT CUSTOMERS

These are payments made to people who need help to meet a shortfall between their rent and Universal Credit housing costs they get, or other housing related costs. They do not cover service charges, water rates, fuel charges or meal charges.

The Council has a limited budget from which to make awards and therefore awards will be based on individual circumstances. An award will usually only be made for a short period, although longer periods will be considered in exceptional and specific situations.

To apply please complete this form and return it to the address below or hand it in at one of our One Stop Shops. Please answer all the questions as fully as possible and give supporting evidence.

Part 1: Your personal details

Name: / Office Use Only:
Date received:
(stamp)
Address:
National Insurance Number:
Date of Birth:
Contact number:
Universal Credit reference:

Please return completed application form and additional evidence to:

South Gloucestershire Council, Benefit Service, Civic Centre, High Street, Kingswood, Bristol, BS15 9TR

Or you can hand it in to one of our One Stop Shops at:

Thornbury One Stop Shop, Thornbury Library, St Mary Street, Thornbury
Yate One Stop Shop next to Yate Leisure Centre, Yate
Kingswood One Stop Shop, Civic Centre, High Street, Kingswood
Patchway One Stop Shop, Patchway Hub, Rodway Road, Patchway

If you have any queries or problems completing the form you can contact

the Benefit Service on: 01454 868002

1. Why are you applying for a Discretionary Housing Payment (DHP)?

Please tick those that apply –

A / You have a shortfall between your Universal Credit housing costs element and the rent you pay
B / Your Universal Credit entitlement is currently being reduced due to the benefits cap
C / You are a registered social landlord tenant and your Universal Credit Housing costs element is restricted due to extra room(s)
D / The income used in the calculation means that you are not entitled to full Universal Credit Housing costs
E / You have a non-dependant deduction which reduces your Universal Credit Housing costs entitlement.
F / Help with any other housing related costs (other than utility bills) – use section 9 of this form to give further details. You will need to provide supporting evidence of these costs

If the housing costs on your Universal Credit, is restricted because you have more rooms than you need under the Social Sector Size Criteria, please tick any of the following that may apply –

1 / You provide foster care
2 / You have children who are unable to share with other children owing to their medical condition/s
3 / You have a non-dependent who usually lives with you but serves in the armed forces or reserves
4 / Your property has been adapted to meet the disability needs of you, your partner or a member of your family
5 / You require and receive regular overnight care from someone who does not normally live with you

3. How much can you pay towards your rent?

(A DHP can only be awarded for up to the amount of the shortfall between your rent and your Universal Credit Housing element)

£ per week

4. How long do you expect to need a DHP for?

5. About your household

Please tell us about all the people who normally live with you, such as a partner, children, any other adults. If you live alone, please write “none”.

Name / Relationship to you / Date of Birth / Gender / National Insurance number / Income / amount

Please use space below to add any additional members of the household

6: Tell us about your tenancy

Who do you rent your property from?

Merlin Housing Society
A Registered Provider / Housing Association
A Private Landlord

Please provide evidence of your current rent. For example, your tenancy agreement.

7: How many rooms are there in your property?

In the whole building / Just for you and your household / That you share with other people
Living Rooms
Bedsitting Rooms
Bedrooms
Bathrooms
Kitchen
Other Rooms
(please specify)

8. What steps are you taking to meet your housing costs in the future?

Please provide additional details in the spaces provided to any that apply

Have you asked the landlord if they are prepared to reduce the rent?
What steps are you taking to find employment?
If you are working, can you increase your hours?
If you are not able to increase your hours, please state why
If you are unable to meet the on-going rent costs currently, what steps have you taken to find somewhere else to live?
Have you reviewed your budgeting arrangements? If you have debts, please state what steps you have taken with regard to seeking debt advice

9. Why do you need to live in your current property?

Please provide details and evidence if applicable

10. Do you have any special expenditure? For example medical expenses, specific debts, etc. If so, please give details and provide evidence of this expenditure

11. Are you in rent arrears? Yes / No

If yes how much? £
What period are they for?

12. Please tell us about any special circumstances that apply to you or members of your household, e.g. disabilities, special educational needs, or family members living with you on a temporary basis

· Provide the date they started, and if possible, a date that they may end.

13. Is there anything else you would like to tell us? Please use the space below or provide details on a separate sheet

14: Payment of your Discretionary Award

How do you want us to pay your Discretionary Housing Payments, should an award be made?

Please circle your choice and provide the required details where appropriate.

I want my benefit to go straight into my bank or building society account / Yes / No / Name of Bank:
Account Holder:
Sort Code:
Account Number:
Roll Number (where applicable):
I want my benefit to go straight into my landlords bank or building society account / Yes / No / Name of Bank:
Account Holder:
Sort Code:
Account Number:
Roll Number (where applicable):

DECLARATION

This is my claim for a Discretionary Housing Payment.

· I declare that the information I have given on this form is correct and complete to the best of my knowledge

· I authorise the Council to make any necessary enquiries to verify the information given on this form

· I understand that you may share the information I have given on this form with other Council departments or other bodies responsible for auditing and administering public funds

· I understand that if I give information that is incorrect or incomplete I may be prosecuted

· I know that I must notify the Council immediately, in writing, of any changes in circumstances

SIGNATURE OF CUSTOMER OR APPOINTEE

DATE ……………………..

If completed by an appointee, please give details

Name:

Contact details:

Relationship to customer:

Please ensure that you provide your Universal Credit award, proof of income for non-dependants in your home and proof of your current rent, e.g. tenancy agreement.

Please complete this part if you are applying for a Discretionary Housing Payment due to the Benefit Cap.

You should return this along with the completed application form to prevent any delay.

I give consent for South Gloucestershire Council to confirm with the Department of Work and Pensions that I am participating in employment support provided at Job Centre Plus.

Name: ……………………………………………………………………………………………….

Housing Benefit claim reference: …………………………………………………………….

Date of Birth: ……………………………………………………………………………....………

Address: ……………………………………………………………………………….………..…