Shetland Islands Citizens Advice Bureau Social Security Benefit Check Form - Notes

The form will allow us to check that you are receiving all the benefits that you are entitled to.
If we identify benefits that you are not currently claiming, we can guide and assist you through the benefit application process.
Some benefits may be means-tested. Others will not be means-tested but eligibility will depend on your circumstances, for example, ill-health and disability benefits. Please provide full information about your special circumstances so that we can assess your entitlement.
If you arethinking about a change in circumstances (eg starting a new job, co-habiting etc) please provide details at section 9. If you wish, we can then provide you with a benefits comparison, so you can assess how that change in circumstances may affect your benefits.
Remember that many benefits cannot be backdated, so please return your form to us as soon as possible so that you do not lose money in unclaimed benefits.
If you have any queries about completing your form, please call us on 01595 694696.

CRS Number:______

Social Security Benefit Check Form

Section 1 – Your Details

YOUPARTNER

First Name

Surname

Date of Birth

Phone Number

E-mail

Address

Do you get yourState YES/NOYES/NO

Pension?

(please provide details of this under Section 6 – Benefits)

Do you do any paidwork? YES/NOYES/NO

(If you do notdo any paid workplease go to Section 2)

If yes, how many hours

per week do you

usually work?

Are you an employee? YES/NOYES/NO

Are you self employed? YES/NOYES/NO

How much do you earn

before tax?

Is the above figure per

week, month or year?

If you contribute to a

pension how much do

you pay? Is this per

week, month or year?

What is your nationality?

What is your partner’s nationality?

Section 2 – Children

Do you have any dependent children who live with you?YES/NO

Please provide the dates of birth and sex of the child:-

Child 1 Child 3

Child 2 Child 4

Do they have any disabilities?YES/NO

If yes, please state which child/children?

Do they receive Disability Living Allowance?YES/NO

If yes, please state which child/children?

Do you receive Child Benefit for any of the children?YES/NO

If yes, please state which child/children?

Section 3 – Other people

Does anyone else live with you?YES/NO

If yes, please tell us their relationship to you

Are they an adult?YES/NO

Are they employed?YES/NO

Do they receive any benefits?YES/NO

Section 4 – Your home

What Council Tax Band is your house in?

If you get a Council Tax Discount e.g. Single Occupier Discount please tell us which one you get here:

Do you:-

Rent your home from the Council?YES/NO
Rent your home from the Housing Association?YES/NO
Rent your home from a private landlord?YES/NO
Own your home (with or without a mortgage)?YES/NO
Live with family?YES/NO
Other (please state)

Owner Occupied Accommodation

Do you have a mortgage?YES/NO

If so, what is the balance?

If so, what is the current interest rate?

Rented Accommodation

How much is the rent for your home?

Is the rent payable weekly/2 weekly/4 weekly/monthly?

Does anyone else (apart from your partner) pay rent for the property? YES/NO

If yes please state how much of the rent they pay here

How many bedrooms are in your home?

Section 5 – Savings/Capital and Assets

Do you and/or your partner have savings of more than £6,000?YES/NO

(please note that savings include any money in bank/building society/post office accounts, ISAs, bonds, stocks or shares and any cash that you have)

If your savings are higher than £6,000 please state how much they are:-

Do you own any properties other than the home you live in?YES/NO

Do you own or have an interest in a croft:YES/NO

Please state below whether these properties are rented out and whether you derive any income from them:

Do you have any other assets?YES/NO

If so, please state what they are:

Section 6 – Benefits

Are you in receipt of any of the following? If so, please give the details requested.

Name of Benefit / Amount of benefit / How often is it paid? (i.e. weekly/4 weekly) / If you know, please say whether this is income related or based on National Insurance contributions
State Pension / Not applicable
Pension Credit / Not applicable
Housing Benefit / Not applicable
Council Tax Reduction / Not applicable / Not applicable
Child Tax Credit / Not applicable
Working Tax Credit / Not applicable
Child Benefit / Not applicable
Jobseekers Allowance
Employment & Support Allowance
Income Support / Not applicable
Universal Credit
Carers Allowance / Not applicable
Attendance Allowance / Not applicable
Disability Living Allowance / Not applicable
Personal Independence Payment / Not applicable
Any other benefits (please say what):

Is your partner in receipt of any of the following. If so, please give details of their benefits below:

Section 7 – Other Income

Do you/your partner receive any private and /or occupational pensions?YES/NO

Please provide details of how much is payable, to whom and how often:-

Do you or your partner receive any child maintenance?YES/NO

Please provide details of how much is payable, to whom and how often:-

Do you or your partner receive any other income at all?YES/NO

Please provide details below:-

Section 8 – Health & Care

Do you or your partner have any health problems or disabilities?YES/NO

If yes, please provide brief details below:-

Do you or your partner have any care needs or mobility problems as a YES/NO
result of your health problems or disabilities?

Does anyone claim Carers Allowance for helping you or your partner?YES/NO

Are you unable to work due to ill health or disability?YES/NO
If yes, since what date?

Is your partner unable to work due to ill health or disability?YES/NO
If yes, since what date?

Do you care for at least 35 hours/week for someone who has a disability?YES/NO

If yes, is this someone who lives with you?

Does your partner care for at least 35 hours/week for someone who has YES/NO
a disability?

If yes, is this someone who lives with you?

Section 9 – Other Information

Please use this space to tell us anything else that might be relevant to your benefit entitlement or to explain things a bit more if you think this might help us.

For example, tell us if you are pregnant or if you are aware of any forthcoming changes in your circumstances. Also, if you are having any money deducted from existing benefits to repay an overpayment or for costs such as rent, fuel etc, tell us here.

Do you currently have no funds and need urgent help?YES/NO

Section 10 – Declaration

We will use the information you have provided on this questionnaire to carry out an income related benefits check. An adviser will then contact you to discuss this and ask you for further information if required. If there are benefits you could claim we can let you know how to claim these. You can come into the Bureau for further assistance with applications should you require it.

We need to keep a record of your case. All information is kept securely and will be dealt with in strict confidence. We would ask that you and your partner sign the following declaration to confirm that we can keep such a record.

I give permission for Shetland Islands Citizens Advice Bureau to keep a record of the information above in order to advice me about relevant benefits. I understand that this information will be kept confidential and stored in accordance with the Data Protection Act 1998.

You

Signed ______Dated ______

Your partner

Signed______Dated______

Section 11 – Authority for someone (partner, relative, friend, interpreter, carer) to act on your behalf

Shetland Islands Citizens Advice Bureau is not allowed, under the Data Protection Act, to discuss anything about your enquiry with a 3rd party without you giving authority for us to do so. If you require a third party to help you with your case and you therefore want us to discuss your case with them then please complete the information below, providing the name and contact details of the authorised person.

I authorise:...... (name of 3rd party)

Address:......

...... (of third party)

Telephone number...... (of third party)

To act on my behalf concerning my possible benefit entitlement

Signature (of client):...... Date:......

Form title: Benefit Check Form, May 2016