APPLICATION FOR DISCRETIONARY HOUSING PAYMENT

Name: _ _______

Address:

I, or a member of my family, will suffer exceptional hardship if I do not receive extra benefit. This is because:-

(If you moved in the last 12 months, please state your previous address).

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2. If this was after 2 January 1996, did you ask for a Pre-Tenancy Determination (PTD)?

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If yes, please tell us how you were able to afford it. (e.g. in work)

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What was the outcome?

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5. Have you tried to find cheaper accommodation?

Is there any reason why you could not move if you found cheaper accommodation?

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(a) How much notice would you have to give?

(b) When does your current tenancy end?

6. Do you have any relatives or friends who could help you? Could they provide you with accommodation,

If only temporarily? Could they, or anyone who lives with you, help you with the rent?

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7. Do you or a member of your family, have any disabilities or health problems?

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8. Have you recently been bereaved?

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9. Do you have any rent arrears?

If so give details.

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10. Do you have any other debts (HP, loans, fines etc.)? Please give full details.

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11. Do you have any savings or property (including holiday homes or time shares abroad)?

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12. Is there anything else you think that we should know?

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I understand that Discretionary Housing Payments are not part of the Housing Benefit and Council Tax Benefit scheme and are therefore not subject to the usual appeals process.

I declare that to the best of my knowledge the information given is true and correct and I authorise the Council to verify the information if they wish to do so.

I undertake to notify the Council at once of any change in my/our circumstance/household composition. I understand that failure to do so may result in an overpayment occurring which may be recovered by the Council.

I understand that some of the information I have given is held on computer and is therefore covered by the Data Protection Act 1998.

If your application is successful please indicate whether you want the payments to be made to yourself or your landlord by ticking the appropriate box.

Claimant's Signature:

Date:

Partner's Signature:

Date:

FINANCIAL STATEMENT

FOR THE PURPOSE OF DISCRETIONARY HOUSING PAYMENTS

Claim No.:

Is there a deficit of weekly income over expenditure? YES/NO

Dischouspay/lwj