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APPLICATION FOR A DISCRETIONARY HOUSING PAYMENT

Isle of Wight Council

	APPLICATION FOR A DISCRETIONARY HOUSING PAYMENT
	Use this form to apply for additional help with Housing Benefit or Council Tax benefit.
	Your Details

Housing Benefit Reference

*	Forename
	Middle name/Initials
*	Surname

Building/house name/number

Street address

Town Name

County

Postcode

Telephone Number
(include area code)

Email address

Are you applying for additional help with

your rent

your council tax

Rent/ Council Tax Details

*	How much is your rent?	� /week
*	How much is your Council Tax?	� /week
*	When did your tenancy commence?
*	When does your tenancy end?
*	How much Housing Benefit do you receive?	� /week
*	How much Council Tax Benefit do you receive	� /week
*	How much rent does this leave for you to pay?	� /week
*	How much Council Tax does this leave for you to pay?	� /week
*	Please give the reason why you consider that you should receive additional assistance.

IF YOU HAVE LIVED AT YOUR CURRENT ADDRESS FOR MORE THAN SIX MONTHES PLEASE CLICK HERE.

IF YOU HAVE NOT LIVED AT YOUR CURRENT ADDRESS FOR MORE THAN SIX MONTHS PLEASE CLICK 'NEXT' BELOW.

	New Tenancies Only
	To help the Council decide on whether or not you are eligible for an award of Discretionary Housing Payment, we will need to ask you the following questions. Please answer each one, giving as much detail as possible.

Did you apply for a Pre-Tenancy Determination? (This question will apply if you are a private tenant.)

Yes

If yes, what was the outcome?

If no, why not?

Why did you leave your last address?

When you accepted the tenancy how did you expect to pay the rent?

	All Tenants
	To help the Council decide on whether or not you are eligible for an award of Discretionary Housing Payment, we will need to ask you the following questions. Please answer each one, giving as much detail as possible.

Have you tried to find cheaper accommodation?

Yes

If you ticked yes, what was the result? If you ticked no, why not?

Are there any reasons why you cannot move? If yes, please give details.

If no, please put N/A

Do you or any members of your family have any disabilities or health problems that contribute to your need for a Discretionary Housing Payment?

Yes

If yes, please explain

Are you in arrears with your Rent?

Yes

If yes, how much rent do you owe?

�

What date are the rent arrears in respect of?

Are you in arrears with your Council Tax?

Yes

If yes, how much Council Tax do you owe?

�

What date are the Council Tax arrears in respect of?

Please list your weekly income

	Your Expenses
	Please complete the following section regarding your expenses. Please indicate whether the payments are weekly or monthly.

Water

�

Monthly

Weekly

Gas

�

Monthly

Weekly

Electric

�

Monthly

Weekly

Food

�

Monthly

Weekly

Catalogues 1

�

Monthly

Weekly

Catalogues 2

�

Monthly

Weekly

Catalogues 3

�

Monthly

Weekly

Miscellaneous (Please give details)

Further Information Required

Has your landlord asked you to leave your home because of the rent arrears owing?

Yes

If yes, please give details

Have you any outstanding debts that you are not paying off?

Yes

If yes, please give details

If a Discretionary Housing Award is not awarded, how will you pay the rent?

If this is a request for a further award, please detail here and provide evidence of the actions you have taken to seek an alternative solution.

If not, please enter N/A

Is there anything else we should know?

If not, please enter N/A

Declaration

I declare that the information I have given is true and complete and I authorise the Council to check the information if it wishes to do so. I undertake to notify the council immediately, in writing, of any changes in the personal or financial circumstances of myself and any member of my household.

I am aware that if I deliberately make a false statement or withhold information in order to Obtain Discretionary Housing Payments, the Council will ask me to repay any amount awarded as a result of the incorrect information provided.

	Your Signature	Signed ............................................................................... Name................................................................................. Date...................................................................................
	Your Partner's Signature	Signed ............................................................................... Name................................................................................. Date...................................................................................

If you would like more information or advice on how to complete this form please telephone us on: 01983 823950.

Completed applications forms should be returned to:

Isle of Wight Council
Housing & Council Tax Benefit
Council Offices
Sandown
Isle of Wight
PO36 9EA

Or in person at any of our local offices.

We will endeavour to process your application within 5 working days

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