Isle of Wight Council

	HOUSING BENEFIT MISSING CHEQUE FORM
	Use this form to report a lost/ non-received cheque and to request a replacement.
	PLEASE NOTE: THE COUNCIL WILL CONSIDER EACH APPLICATION FOR REIMBURSEMENT ON ITS OWN MERITS AND WILL NOT AUTOMATICALLY REPLACE THE LOST / STOLEN CHEQUE If you would like more information or advice on how to complete this form please telephone us on: 01983 823950
	Your Details

*	Forename
*	Surname

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

Cheque Details

	HB Ref. No/Payee Name
	Cheque Number
	Amount �
	Date of cheque
	Rent Allowance

WARNING: To give false information may result in prosecution.

I wish to report that the above cheque has been lost / not received by me, and that a replacement be made.

*

I have / have not reported the loss to the Police at.

If not reported yet the loss should be reported immediately

*	Date the cheque should have been received
*	Is there a regular postman?	Yes No
*	What time does the cheque normally arrive
*	Do you have a personal letterbox	Yes No

*	Is there a lock on the letterbox?	Yes No
*	How are the letters received / distributed?
*	Was any mail delivered on the day the cheque should have arrived	Yes No
*	Who distributed the mail that day
*	Were you at home at the time of delivery of the mail	Yes No
*	Who else could have picked up the mail after it was delivered
*	Do you know any neighbours with a similar name or address? (Please identify)
*	Have you made any enquiries with them?	Yes No
*	Have you previously reported the loss or non receipt of other payments (give details)
*	If you think that the cheque has been stolen do you have any idea who might have taken it?

Declaration

Please print this form and fill this section in by hand before returning your form to the address below.

I declare that I have not received the above cheque and it has not been cashed by me, or with my knowledge or authority. I undertake to notify the Benefits Office immediately, should the missing cheque come into my possession and return it to the Council. I understand that if I give false information to the Council, I may be prosecuted.

*

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 14 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