Application for Discretionary Housing Payment

APPLICATION FOR DISCRETIONARY HOUSING PAYMENT

For Official Use Only / Reference No.:
Date of Issue:

Name: ______

Address:

I, or a member of my family, will suffer exceptional hardship if I do not receive extra benefit. This is because:-

When did you move to this address?

(If you moved in the last 12 months, please state your previous address).

____

2.If this was after 2 January 1996, did you ask for a Pre-Tenancy Determination (PTD)?

____

Were you able to afford the rent when you moved in?

If yes, please tell us how you were able to affordit. (e.g. in work)

____

Have you asked the Landlord to reduce the rent?

What was the outcome?

____

5.Have you tried to find cheaper accommodation?

Is there any reason why you could not move if you found cheaper accommodation?

____

(a)How much notice would you have to give?

(b)When does your current tenancy end?

6.Do you have any relatives or friends who could help you? Could they provide you with accommodation,

If only temporarily? Could they, or anyone who lives with you, help you with the rent?

____

7.Do you or a member of your family, have any disabilities or health problems?

____

8.Have you recently been bereaved?

____

9.Do you have any rent arrears?

If so give details.

____

10.Do you have any other debts (HP, loans, fines etc.)? Please give full details.

____

11.Do you have any savings or property (including holiday homes or time shares abroad)?

____

12.Is there anything else you think that we should know?

____

I understand that Discretionary Housing Payments are not part of the Housing Benefit and Council Tax Benefit scheme and are therefore not subject to the usual appeals process.

I declare that to the best of my knowledge the information given is true and correct and I authorise the Council to verify the information if they wish to do so.

I undertake to notify the Council at once of any change in my/our circumstance/household composition. I understand that failure to do so may result in an overpayment occurring which may be recovered by the Council.

I understand that some of the information I have given is held on computer and is therefore covered by the Data Protection Act 1998.

If your application is successful please indicate whether you want the payments to be made to yourself or your landlord by ticking the appropriate box.

Payment to landlord /
Payment to myself /

Claimant’s Signature:

Date:

Partner’s Signature:

Date:

FINANCIAL STATEMENT

FOR THE PURPOSE OF DISCRETIONARY HOUSING PAYMENTS

Claim No.:

Is there adeficit of weekly income over expenditure? YES/NO

Income / Weekly
Monthly
Quarterly / Expenditure / Weekly
Monthly
Quarterly / Reasonable
when compared to "Trigger Figures"
Housing Benefit / Rent
Council Tax Benefit / Council Tax
Income Support / Electricity
Job Seekers Allowance / Gas
Child Beneift / Water
Maintenance / Oil
Employment / Coal
DLA Care / Phone
DLA Mobility / Food
Other / Clothing
Motoring Expenses
TV Licence
Other
Total Income / Total Expenditure

Dischouspay/lwj