Isle of Wight Council

	BENEFITS RECONSIDERATION REQUEST
	Completed application forms should be returned to: Isle of Wight Council, Council Offices, Sandown, Isle of Wight PO36 9EA

Please read the 'Notes for Disputing Benefit Decisions'  before completing this form

Claim Reference:

*	Forename
	Middle name/Initials
*	Surname

*	Building/house name/number
*	Street address
*	Town name
	County
*	Postcode
	Tel number (include area code)
	Email address
	Fax

Please reconsider the decision dated

If you do not know the date of the decision, please use the space below to give us as much information as you can about the decision:

	Please use the space below to tell us why you disagree with the decision or to give us any extra information that you would like us to consider:

DECLARATION - I declare to the best of my knowledge the information is true and complete. I authorise the Isle of Wight Council to verify the information if they wish to do so.

* Signed............................................................... * Name................................................................ * Date..................................................................

	Data Protection Act 1998
	This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request. The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest. Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law. Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

Date printed: 07/03/2013