PART ONE – THE HOUSEHOLD

How many people aged 18 or over usually live in the property?

(You don’t have to give their names, just the number of people, including

the carer and the person receiving care)

Is there anyone who normally lives in the property, not included above,

who is not there at the present time? (e.g. working abroad) Yes No

Are there any people aged 16 and 17 living in the property? Yes No

If yes, how many?What are their dates of birth?

Have you applied for anyone else in the house to be disregarded? Yes No

If yes, please give their name and the reason for the claim:

Name:
Reason for claim:

PART TWO – THE CARER

Name and address of carer (if different from above)
How many hours a week does the carer provide care?
What date did the carer begin providing this care? (If you are claiming prior to the start of the financial year, please provide documentary evidence to support the application e.g. Carer’s Allowance award notice) / Day / Month / Year

PART THREE – THE PERSON RECEIVING CARE

Who is the person receiving care?Name:

Do they live at the same address as the carer?Yes No

Is the person who is receiving care in receipt of any benefits? Yes No

If yes, please state which benefits they receive and the dates of entitlement below (photocopied documentary proof should also be sent with this form. Please do not send original documents)

Benefit: / Start date:
Benefit / Start date:

Is the person receiving care related to the carer?Yes No

If yes, please state the relationship

If the person receiving care is the son/daughter of the

Carer, please provide their date of birth.

Please Note – if the son/daughter of the carer is under 18 years of age, this discount cannot apply.

Please give full details of the care being provided, in the box below

PART FOUR – DECLARATION

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

Signed / Date
Daytime telephone number