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Change of Circumstances End of Income Support/Income Based Job Seekers Allowance

Isle of Wight Council

Change of Circumstances End of Income Support/Income Based Job Seekers Allowance

	Please complete this form if your Income Support or Income Based Job Seekers Allowance has ceased.
	Completed application forms should be returned to: Isle of Wight Council, Council Offices, Sandown, Isle of Wight PO36 9EA

	For Official Use Only	Date received
	HB Ref:
	Date of Request:
	Date of Issue:

Benefit Claim number

Part 1 About you and your partner

Do you have a partner who normally lives with you?

By partner we mean someone to whom you are married or live with as if you are married to them or a Civil Partner or a person you live with as if you are Civil Partners.

Yes

If you have a partner, you must answer all the questions about them, as well as yourself.

		You	Your partner
	Last name
	Other names
	Any other last names you have used
	Title (Mr, Mrs, Ms and so on)
*	Address including flat, room or caravan number if you have one. Do not tell us your partner's address if it is the same as yours.

Do you currently reside at this address?

Yes

Date of birth

dd/mm/yyyy

National Insurance number

You can find this on payslips or letters from social security or the tax office. We cannot decide your claim if we do not have your National Insurance number.

If you or your partner do not have a National Insurance number, or cannot find it, tick appropriate box.

Your daytime phone number.

You do not have to tell us this, but it may help us to deal with your claim more quickly.

Section 1 You and your partner's earnings

Part 1 About you and your partner

Do you or your partner work (either paid or unpaid)?

Yes

If 'yes', please fill in this section

If 'no' go to page 4 if you are self-employed, otherwise continue to Section 2.

Evidence you must send us to receive benefit:

We need proof of your and your partner's pay for all jobs. If you do not send us this, it could delay any benefit and we may contact your employer. See section 7 for more details of necessary proof. If you make payments to a private pension scheme we need proof of the policy and payments. If you or your partner are self-employed, you must send us your or their most recent accounts. If you cannot provide these, or have only recently become self-employed or returned to self-employment, please contact our Benefits Department.

	Section 2 About Benefits and Pensions
	Read the list of benefits below and tell us about any you or your partner are getting now or have claimed.

* Bereavement Allowance

* Child Benefit

* Children's Tax Credit

* Statutory Paternity Pay

* Fostering Allowance

* Guardian's Allowance

* War Disablement Benefit, War Pension or War Widow's Pension

* Widow's or Widower's Benefits

* Adoption Pay

* Working Tax Credit

* Statutory Sick Pay or Statutory Maternity Pay

* Pension Savings Credit

* Incapacity Benefit

* Industrial Injuries Disablement Benefit

* Industrial Death Benefit

* Carers Allowance

* Contribution-based Jobseeker's Allowance

* Maternity Allowance

* Retirement Pension

* Severe Disablement Allowance

* Deferred pensions (if over 60 years of age)

* Disability Living Allowance(Care or Mobility)

* Carers Allowance paid to someone else & look after you

Are you or your partner getting any benefits or waiting to hear about benefits you have claimed?

Yes

If 'yes', tell us about the benefits below. Tell us the full rate of the benefits before any deductions.

If 'no', go to Section 3

If you are over 60 years of age do you have a pension from your previous employment which you have chosen not to take yet?

Yes

Who is the pension with?

You

Your partner

The name of the benefit or pension

Waiting to hear

Getting now

How much?

How often?

�

every

You

Your partner

The name of the benefit or pension

Waiting to hear

Getting now

How much?

How often?

�

every

The name of the benefit or pension

Waiting to hear

Getting now

How much?

How often?

�

every

Are you or your partner waiting to hear about any pension, benefit allowance or other income listed above?

Yes

If you need to tell us about more benefits continue here

Section 3 About Other Money Coming In

Do you or your partner, or any children you are claiming for, have any money coming in (or expect to have some money coming in) that you have not already told us about on this form?

This includes occupational and private pensions; maintenance or child support for you, your partner or any of the children you have told us about on this form; money from a trust fund; training allowances; a student grant or loan; and any cash payments. Also tell us about any money you get from people living in your house as boarders, lodgers or subtenants. You do not need to tell us about payments from the Independent Living Fund, the Eileen Trust or the MacFarlane Trust.

Yes

If 'yes', tell us about the details below.

If 'no', go to Section 4

Other Money 1

	Where is the money from and what is the money for?
	Who gets it?
	How much do they get and how often?	� every
	When did they start getting this income?
	When is the income likely to go up?

Other Money 2

	Where is the money from and what is the money for?
	Who gets it?
	How much do they get and how often?	� every
	When did they start getting this income?
	When is the income likely to go up?

Please give details of any further money that you receive. Please give full details as above.

Does anyone owe money to you, your partner, or any children you are claiming for?

Yes

what for?

how much?

Are you expecting to get any money in the next 12 months? For example, a redundancy payment or a payment instead of notice or holiday.

Yes

what for?

how much?

	Section 4 Money You Pay Out (Outgoings)
	We only take account of the following outgoings when we assess your entitlement to benefit.

Do you or your partner help to support a son or daughter who is under 25 and at university or college? If 'Yes', send in proof of the course, term dates and how much money you give. Please send us the loan assessment form.

Yes

Do you or your partner pay a registered childminder, nursery or after-school club to look after any children under 15 (under 16 if they are disabled)?

Yes

If 'Yes', please send proofs of payments made and the childminder's or scheme's registration number and fill in the boxes below.

	Name of child
	Weekly amount you pay	� /week
	Name, address and registration number of childminder or scheme

	Name of child
	Weekly amount you pay	� /week
	Name, address and registration number of childminder or scheme

	Name of child
	Weekly amount you pay	� /week
	Name, address and registration number of childminder or scheme

Further details of children, amount paid and childminder or scheme. Please give details as above.

Section 5 You and Your Partner's Savings and Money

Do you, your partner or any children you are claiming for have any cash, current accounts, savings accounts and so on.

Yes

If 'yes', tell us about the details below.

If 'no', go to Section 6

If any of these are joint accounts, enter the total amount in one column only.

	You	Your partner
Description	Amount and where it is held	Amount and where it is held
Cash	�	�
Bank (current accounts)	�	�
Please give the name of the bank and account number and the amount held in each account .
Bank (deposit accounts)	�	�
Please give the name of the bank and account number and the amount held in each account .
Building society accounts	�	�
Please give the name of the bank and the account number and the amount held in the account.
Foreign accounts	�	�
Please give the name of the bank and the account number and the amount held in the account.

	You		Your partner
	Issue number	Number of units	Issue number	Number of units
National Savings Certificates Please give the issue number and number of units.


Premium bonds	�		�
Post office accounts	�		�
Post office accounts	�		�
	Company	Number held	Company	Number held
Stocks, bonds and shares (including unit trusts, government stocks and so on) Please give the name of the company and the number held.


Personal Equity Plan (PEP)	�		�
TESSAs	�		�
ISAs	�		�

You

Your partner

Description

Amount and where it is held

Accounts with other financial organisations (such as insurance companies).

�

Please say where they are held.

Any other type of savings

�

Please give the name and type of account, the amount and where it is held.

Have you or your partner received a Far Eastern Prisoner of War compensation payment?

Yes

Do you or your partner own or partly own any land, property or timeshare other than the place where you live, either in the UK or abroad?

Yes

If 'Yes', please give the address and details of how much it is worth.

�

If you have a mortgage or loan for this, how much is left to pay?

�

Does anybody owe you or your partner any money?

Yes

Evidence you must send us to receive benefit. We need to know about any savings and property that you or your partner have. We must see proof of your savings. For all bank accounts we must see two full months' statements.

Section 6 Other Information

	If you have a child who receives an income or benefit (other than child benefit) or has capital over �3000, please give details.
	Please use this space to tell us about any other change in your circumstances that may affect your claim such as household, rent or any other changes.

We may need to write to you for evidence of this.

Section 7 Checklist

Before you return this form - have you done the following?

Have you given your name and address on the application form?

Have you answered all the questions on the form?

Have you enclosed documentary evidence of your income and capital?

Have you read and signed the declaration at the bottom of this page?

Proof of income

If you are employed, you must provide five wage slips in a row (if you are paid weekly), three wage slips in a row (if paid every two weeks) or two wage slips in a row (if paid monthly). Or, you can provide a letter from your employer on official company paper. If you cannot provide all the necessary slips return this form now and send the further information when available.

If you make payments to a private pension scheme you must provide proof of the policy and payments.

If you or your partner are self-employed, you must send us your most recent accounts. If you cannot provide these, or have only recently become self-employed, please contact our Benefits Section.

If you receive any benefit, we will need to see your benefit book or notification of the amount you receive from the DWP. All documents must be originals.

Proof of savings and investments

We will need to see two recent full months' bank statements for all accounts, plus statements, passbooks or certificates showing all savings and investments and how they are invested. All documents must be originals.

Remember, If you do not provide the evidence we ask for on this form, we will not be able to pay you any benefit. If you cannot send the evidence we need at the moment, send the form back to us now and send the evidence later.

	Section 8 Your Declaration
	Even if someone else has filled in this form for you, you must sign this declaration if you can. If you have a partner, it would be helpful if they sign below to confirm all the details about them are correct. But they do not have to sign. Please read this declaration carefully before you sign and date it. I understand the following: ? If I give information that is incorrect or incomplete, you may take action against me. This may include court action. ? You will use the information I have provided to process my claim for Housing Benefit or Council Tax Benefit, or both. You may check some of the information with other sources as allowed by the law. ? You may use any information I have provided in connection with this and any other claim for social security benefits that I have made or may make. You may give some information to other organisations, such as government departments, local authorities and private-sector companies such as banks and organisations that may lend me money, if the law allows this. I know I must let the Council know about any change in my circumstances which might affect my claim. I declare the information I have given on this form is correct and complete.

*	Signature of person claiming	Signed ............................................................................... Name................................................................................. Date...................................................................................
*	Partner's signature	Signed ............................................................................... Name................................................................................. Date...................................................................................

Please complete this section if this form has been filled in by someone other than the person claiming.

As far as possible, I have confirmed with the person claiming that the answers I have written on this form are correct.

(Please tick to agree with this statement)

	Please tell us why you are filling in this form for the person claiming.
	Relationship to the person claiming
	Signature of the person who filled in this form	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