Housing and Council Tax Support

Change of Circumstances Form

It is important to tell us when your circumstances change

If you receive Housing and/or Council Tax Support it is important to tell us about any changes in your circumstances that could affect the amount of benefit you are entitled to. Examples of changes are stated overleaf. If you are unsure as to whether or not a change needs reporting please contact the Benefits Section on 01246 242436 for information and advice.

If you do not tell us about a change in your circumstances within one month of it happening you may lose out on benefit to which you are entitled or we may pay you too much benefit and you will have to pay us back.

Part 1 About you
Your full name /
Your address (the address you are getting benefit for now) /
Your benefit reference (if known) /
Part 2 Your contact details
Telephone number(s) / /
Email address /
Part 3 About the change(s)
Please give full details of the change below and provide any appropriate evidence.

You must notify the Council of any of the following change of circumstances:

  • A change in your rent (unless you are a Bolsover District Council tenant);
  • A change in the status of your Non-dependant/Second Adult (for example your non-dependant starts or finishes work, or their income changes);
  • A change in family circumstances affecting the applicable amount (for example you have a child, someone leaves or joins the household or you are awarded a disability related income);
  • A change in capital or income;
  • A change relating to payment of Housing Benefit to your Landlord (for example your Landlord changes address or banks);
  • A change of address;
  • Any absences from the property exceeding a normal two week holiday.

NB – Please note that the above list is not exhaustive and is just some examples of changes that would need reporting. If you have any change in circumstance, it is best to contact us on 01246 242436 and make us aware of it. We can then decide if your Benefits will be affected.

Part 5 Declaration
Please read this declaration carefully before you sign and date it. I understand the following:
• If I give information that is incorrect or incomplete, you may take action against me. This may include court action.
• You will use the information I have provided to process my claim for benefit. You may check some of the information with other council departments, rent offices, other councils and government organisations.
• You may use any information I have provided in connection with this and any other claim I have made or may make for state benefits or Discretionary Housing Payments. You may give some information to other government organisations, if the law allows this.
• You may also use any information I have provided to keep mine, or my partner’s, Council Tax account up to date, and to award or remove any relevant discounts.
I know I must let you know about any change in my circumstances (or the circumstances of anyone in my household) which might affect my claim. I know I must let you know about any change as soon as I know about it.
I declare the information I have given on this form is correct and complete and that I have read and understood the declaration above.
Signature of
Person claiming: / / Date: /
Partner’s signature: / / Date: /
Part 6 Returning this form

You should never delay returning this form to us. You can hand the form in at one of our Contact Centres, email it to post it to:

The Benefits Section

Bolsover District Council

The Arc

High Street

Clowne

S43 4JY