Classification: OFFICIAL

Your ref
Our ref
Contact / Council Tax
email /
Tel / 0333 200 6900

Finance Department, Organisation & Governance Directorate, Council House, Corporation St, Derby DE1 2FS www.derby.gov.uk

COUNCIL TAX:

APPLICATION FOR EXEMPTION OR DISCOUNT: SEVERE MENTAL IMPAIRMENT

Property address:

The full council tax bill assumes that there are 2 adults residing in a property. However, for Council Tax purposes, some people are not counted as living at the property if certain circumstances apply. These people are disregarded.

An exemption will apply where all occupiers of the above address are disregarded and classed as severely mentally impaired.

A discount will apply where all but one adult is disregarded and classed as severely mentally impaired.

1 / How many people over 18 years live in the property above?
2 / How many people over 18 years are severely mentally impaired?
3 / Full details of people who are severely mentally impaired.
First person / Second person (if any) / Third person (if any)
Last name
First name/s
Date of birth
Doctor’s name
Doctor’s address
4 / If the persons above get or are entitled to any of these benefits please tick all boxes which apply
Benefit / First
person / Second
person / Third person
Personal Independence Payment, payable at highest rate or middle rate or the care component of a Disability Living Allowance
Incapacity Benefit
Attendance Allowance or constant Attendance Allowance or Severe Disablement Allowance
Increased Disablement Pension where constant attendance is needed
Disability Working Allowance
Unemployability Supplement
Disability Premium included in Income Support
Employment and Support Allowance
The disability element of Working Tax Credit
Armed Forces Independence Payment

Fair Processing Notice

To improve our customer services to you we may share information with other Council departments including our Benefits service, Sundry Debts team or Derby Advice if you tell us anything which affects another Council service or an entitlement to another service. We will treat all information provided in confidence and in accordance with the Data Protection Act 1998. It will be used for the purpose of processing and administering your Council Tax. It may also be used for the prevention of fraud, misuse of public funds and any legal or statutory requirements. It may also be shared with other third parties under relevant legislative powers for a similar purpose. Information about you and the Data Protection Act can be obtained from the Data Protection Officer, The Council House, Corporation Street, Derby DE1 2FS.

I declare that to the best of my knowledge the information given on this form is true and complete.

I give permission on behalf of the applicant(s) to ask the doctor(s) above to confirm medical condition of the applicant(s).

Signed...... Date......

Full Name......

Address......

Phone/email......

Your relationship to severely mentally impaired person(s)......

Classification: OFFICIAL