Isle of Wight Council

BENEFITS APPEAL FORM

	Please read the 'Notes for Disputing Benefit Decisions'  before completing this form
	Completed application forms should be returned to: Isle of Wight Council, Council Offices, Sandown, Isle of Wight PO36 9EA

Complete this form in BLACK ink or biro and return it to the office that sent you the decision

About you

	Title
*	Forename
	Middle name/Initials
*	Surname

The following section is for the claimant only: (Do not complete this section if you are a landlord)

Your date of birth

National Insurance (NI) number Get this from your NI number card, payslips, tax papers or letters from social security.

Your address

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

Benefit Reference Number

If you are a landlord or an appointee, please give the claimants name and address:

*	Forename
	Middle name/Initials
*	Surname

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

Have you arranged for someone to help you with your appeal?

Yes No

	If 'no' please go to the next section ' About the decision'.
	If yes, please tell us their name and address:

*	Forename
	Middle name/Initials
*	Surname

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

*

Please sign here to authorise this person to act for you:

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

About the decision

	Name of benefit or benefits
	Date at the top of the letter about the decision

	About your appeal
	Use the space below to say why you do not agree with the decision.  You must say why you think the decision is wrong. It is not enough to say "I do not agree with the decision" or "The money is not enough."  The reasons you give should be like these examples: - "My rent was �75 per week but you have stated it was �35 per week" - "I moved into the property on 1 November not December." - "You have used the wrong wages to work out my benefit. I only received �250 during the Christmas week." If you are appealing against more than one decision, you must say why you do not agree with each one.  If you are appealing more than one month after the decision was made, you must say why your appeal has been delayed. You must say why you think the decision is wrong. Please use BLOCK CAPITALS and BLACK ink or biro. If you need more space, use another sheet of paper. Remember to put your name and the Benefit Reference Number on any extra sheets of paper.

*

Your signature If someone has been officially appointed to act for you or someone has the authority to act for you, they should sign here.

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

	What to do now
	Make sure you have filled in all parts of this form and signed it. Make sure you have said why you do not agree with the decision.  Take or send this form to the office that sent you the decision.  It will help if you write Appeal on the front of the envelope.  Remember, your appeal must reach our office within one month of the date at the top of the letter telling you about the decision.

	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