Application for Contribution to

Cost of Television Licence

Name of Applicant:Mr./Mrs./Miss………………………………………………..

Address:……………………………………………………………………………

……………………………………………………………………………

Age of Applicant : (years) (Date of Birth)

Age of Spouse : (years) (Date of Birth)

(Note : Where the application is in respect of husband and wife the age and date of birth of both should be shown.)

Date of purchase of Television Licence: …………………………………………..

PLEASE ENCLOSE NEW TELEVISION LICENCE WHEN MAKING YOUR APPLICATION

______

DECLARATIONApplicants are advised to read the notes overleaf carefully before completing this declaration. Any person, who misuses the scheme, by obtaining or attempting to obtain a contribution when ineligible, may forfeit any future entitlement to a contribution.

All personal information provided to Bolsover District Council will be held and treated in confidence in accordance with the Data Protection Act 1998, this may be shared with other council departments or third party organisations

I hereby certify that:

1.I am aged 60 or over

2.My income does not exceed £271.15 per week, as from 1st April 2017 excluding disability payments.

(Note: where the application is in respect ofhusband and wife income means joint income.)

3.(a) I am the main occupier of the premises, OR

(b) I occupy a separate part of the premisesfor which a separate licence is necessary.

SIGNATURE OF APPLICANT………………………….…………..

(Or authorised agent)

DATE ………………………………………

Account Name / Sort Code
Date Received / Account Number
Creditor Number / Checked By
Cost Code / G038/6006 / Authorised By

TELEVISION LICENCE FOR PENSIONERS

Explanatory Notes

The Council will contribute the sum of £12 towards the cost of Television Licence, subject to the conditions as to age, income and residence set out in these notes being met.

1.WHO IS ELIGIBLE?

Eligibility depends on age, (at the time the licence is purchased) income and residence as follows:-

(a)AGE

I am a man or women of not less than 60 years of age.

(b)INCOME

The pensioner or the pensioner and spouse (in the case of husband and wife) must not have an income (or joint income) of more than £271.15 per week, as from 1st April 2017. For this purpose income includes all income receivable by the pensioner or the pensioner and spouse from any source, except that disability pensions or allowances will be ignored.

(c)RESIDENCE

Applicants must reside within the area covered by Bolsover District Counciland must either be a householder (owner / occupier or tenant) or be living in separate part of premises for which a separate licence is required.

2.HOW TO APPLY

(a) It is necessary for you to purchase your licence in the usual way.

(b) Eligible applicants will receive a payment direct into their bank for £12, ensure your bank details have been supplied on page one.

3.COLOUR TELEVISIONS

The Council’s contribution is restricted to £12 irrespective of whether you have a black and white or colour television licence.

4.BLIND PERSONS

A blind person purchasing a licence at the appropriately reduced fee will be entitled to receive a contribution of £12 black and white, £12 colour subject to the conditions as set out in Section 1 above being otherwise met.

When completed this form must be returned to:Bolsover District Council, The Arc, High Street, Clowne, Chesterfield, Derbyshire. S434JY.DO NOT SEND TO NTVLRO RECORDS OFFICE – BRISTOL

This document is available in large print and other formats from any of the Council Offices or by contacting Financial Services on 01246 242476. Please bear in mind we will need a few days to arrange this facility.