Application for Discretionary Housing Payments (DHPs)

Bolsover District Council The Arc High Street ClowneDerbyshire S43 4JY

01246 242436 benefits@bolsover.gov.uk

Title: Mr. Mrs. Miss Ms. Other (please state)

Last name: Other names:

Date of birth: xx / xx / xx

Do you have a partner who normally lives with you?: Yes No

Their title: Mr. Mrs. Miss Ms. Other (please state)

Their last name: Their other names:

Their date of birth: xx / xx / xx

Benefit claim number (if known):

National Insurance (NI) Number:

Your address:

Daytime telephone number:

Mobile number:

Email address:

Are you liable to pay rent?:

Yes No If ‘yes’, go to question 2 If ‘no’, you are not eligible for DHPs

Are you on any housing waiting lists?:

Yes No If ‘yes’, please answer a) and b) overleaf If ‘no’, please answer c) and d) overleaf

Do you currently receive Housing Benefit or the housing element of Universal Credit?:

Yes No If ‘yes’, go to question 3 If ‘no’, you are not eligible for DHPs

a) Have you tried to negotiate a lower rent with your Landlord:

Yes Outcome?:

No Reasons why not?:

b) Have you considered/tried moving to cheaper accommodation?

Yes No

If ‘yes’, please give details as to why you have not moved. If ‘no’, please advise why not.

Question 1

Question 4

Question 2

Question 3

Could you afford to pay your rent when you first moved into your property?:

Yes No If ‘yes’, how did you afford to pay it?: If ‘no’, why did you take the property?:

a) When did you go on the list?:

b) Whose list are you on?:

c) Please give your reasons for not being on any housing waiting lists?:

d) Would you be happy for your details to be passed over to the Housing Team?:

Yes No

Question 5

When did you move into your current address?: xx / xx / xx

If less than a year ago, please answer the following:

Please tell us your last address: Please tell us your reasons for moving?:

Question 6

Are you behind with your rental payments?:

Yes No If ‘yes’: If ‘no’, proceed to question 8

a) How much are your rent arrears? (please provide proof):

b) Have you received an eviction notice? (If so, please provide a copy):

Yes No

Question 7

Have you tried to find a cheaper home?:

Yes No If ‘yes’, please answer a) and b) below If ‘no’, please answer c) below

a) When did you do this?:

b) What was the outcome?:

c) If you have not tried to find a cheaper home, please tell us why?:

Question 8

Do you have any other adults living with you at this address?:

Yes No (proceed to question 10)

Please advise what amount they contribute to your houshold: per week

It would be reasonable to expect that any adults living with you make a financial contribution towards your household. If they are not, please provide the reasons for this? (Please use a separate sheet if required)

Question 9 - Other people in your household

Question 10 - Income detailsPlease provide a breakdown of yours and your partner’s income:

Income Type How much? (£) How often?

Benefits

Example benefit £100 Weekly

Employment and Support Allowance

Income Support

Job Seekers Allowance

Child Benefit

Working Tax Credits

Child Tax Credits

Incapacity Benefit

Pension Credit

Disability Living Allowance

Personal Independence Payments

Industrial Injuries Disability Benefit

Carer’s Allowance

Universal Credit

Council Tax Support

Bereavement Allowance

Maternity Allowance

Other benefit (please state type)

Other benefit (please state type)

Other income types

Your wages

Your partner’s wages

Statutory or Company sick pay

Company/Occupational pension

Private pension/annuity

Maintenance

Rental income

Money from anyone that lives with you

Student grants, loans, bursaries

Other income (please state type)

Other income (please state type)

Total Income

Question 11Please provide a breakdown of your regular spending (we may require proof):

Expenditure Type How much? (£) How often? Contract end or payment review date

Rent

Council Tax

Water charges

Gas

Electricity

Life Assurance or endowment premiums

House phone

Mobile phone

TV rental licence

Food N/A

Alcohol N/A

Toiletries N/A

Clothing N/A

Cleaning products N/A

Cigarettes or tobacco products N/A

Travelling expenses

Car fuel

Car insurance

Road tax

Prescriptions

Private Health schemes

Satellite or digital TV subscriptions

Internet costs

Childminding

Other expenditure (please state type)

Other expenditure (please state type)

Other expenditure (please state type)

Total expenses

Question 12Do you have any outstanding debts?:

Details of outstanding debts

Current repay-ment amount (£)

Minimum repayment amount (£)

Payment frequency

Original

Debt

(£)

Current balance

(£)

Debt cleared date?

(if known)

Rent arrears

Council Tax arrears

Water rates arrears

Gas arrears

Electricity arrears

Magistrates’ / Court fines

Unpaid maintenance

Credit cards

Catalogue

Loans

Social Fund loans

DWP or HMRC overpayment

Other (please state)

Other (please state)

Total debts

Are you entitled to the mobility element of Disability Living Allowance or Personal Independence Payments, but do not receive any money because you have a motorbility car instead?:

Yes No

Question 13

Do you have any bank, building society, post office or credit union accounts?:

Yes No

If ‘yes’, please provide details:

Name of bank or building society Account number Amount held

Please provide statements/passbooks for all accounts for the last 2 months.

Have you taken any measures to reduce your expenditure?:

Yes (please clarify what measures you have taken below)

No (please advise the reasons why you have been unable to take such measures)

Please advise what actions you have taken, or are about to take, to try and improve your financial situation?:

Seeking work Finding cheaper accomodation

Cancelling subscriptions Reducing expenditure (bills etc)

Claiming other benefits Other (please state)

Please provide further details below:

Question 14

Question 15

Question 16

We may consider including any Personal Independence Payments (Living) /Disability Living Allowance (care)/Attendance Allowance, which is not used towards health related needs, as available income. To ensure that we have a full idea of your health related expenditure please provide a breakdown of any health related needs which have not already been accounted for in the questions above:

Please use the space below to tell us about the reasons why you feel you should be awarded DHP’s. It is very important that you give us as much information as possible. Please continue on a separate sheet of paper if necessary.

Question 17

Question 18

Examples may include: Transportation to medical appointments, Medical aids, Speciality foods/diets, Clothing items etc.

Do you wish to give us permission to discuss your application with your Landlord, or another person who is assisting you with your application?

If so, please indicate below:

I give you permission to share information about my application for a DHP with:

My landlord Citizens Advice Bureau

Derbyshire Law Centre Someone else (please provide details below)

Name:

Address:

Contact number:

Contact email:

Question 19

Housing Benefit claimantsIf you are awarded Discretionary Housing Payments we will pay them in the same way as we pay your Housing Benefit.

Universal Credit claimantsIf the housing element is paid to you we will make payments to you. Please provide your bank details below:

Name of bank or building society:

Whose name is the account in?:

Account number:

Sort code:

Roll number (if applicable)

If the housing element is paid to your landlord, please provide your landlords details below:

Name:

Address:

Contact number:

Contact email:

Check ListPlease ensure that you enclose the following documents when you submit your completed application form.

Proof of your rent (unless you live in a BDC property)

Proof of your income (including a full breakdown of your Universal Credit calculation)

Proof of your expenditure

Proof of any debts (including the repayment arrangements in place)

Proof of your bank, building society, post office or credit union statements

DeclarationIf it is decided that you are entitled to Discretionary Housing Payments they will only be awarded for a limited period of time. This is to allow you time, if you are able, to make changes to improve your financial situation. Should you consider that you are still struggling to meet the shortfall between your Housing Benefit or the housing element of Universal Credit and your rental liability, you can submit a new application for DHP’s.

Please read and sign the declaration below.

I declare that the information given on the form is true and complete. I authorise the Council to check the information if they wish to do so.

I understand the following:

• You will use the information I have provided to process my claim for Discretionary Housing Payments. You may check the information or update my records with other council departments, rent offices, other councils and government organisations.

• You may use any information I have provided in connection with this and any other claim I have made or may make in the future. You may give this information to other government organisations if the law allows this.

• I know that I must let you know about any changes (or changes in respect of persons living within my household) to my income or expenditure that might affect my claim. I know that I must let you know about any changes as soon as I know about it.

I understand that all personal information provided to Bolsover District Council will be held and treated in confidence in accordance with the Data Protection Act 1998. It will only be used for the purpose stated in the declaration above, and by law we may pass your personal information to other local authorities, government departments and agencies to prevent and detect fraud, corruption, money laundering and other crimes. We may share your information with a named representative where this has been requested by you and we have signed authority to do so.

All information held by this Council falls within the scope of the Freedom of Information Act 2000. We could receive a request for information held within your application. However, an exemption exists to protect the disclosure of personal information which would breach the Data Protection Act 1998.

Following receipt of this form the Council will notify you of the DHP decision in writing as soon as it is reasonably practicable.

Your signature: Date: xx / xx / xx

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If you require this publication in large print or another format please call us on 01246 242424

Designed by Bolsover District Council 20-20

Further Advice or assistanceIf you need help or assistance to complete this form you can contact this office Monday to Thursday 8:30am to 5:15pm and on a Friday 8:30am to 5pm. You can contact us be telephone on 01246 242436 or by email at: benefits@bolsover.gov.uk

For independent advice, you can contact the following:

• Citizen’s Advice Bureau – 0300 456 8437

• Derbyshire Unemployed Workers’ Centre – 01246 231441

• Derbyshire Welfare Rights – 01629 531535

• Derbyshire Law Centre - 01246 550674

Please submit this form either by email to benefits@bolsover.gov.uk or by post to Bolsover District Council, The Arc, High Street, Clowne, Derbys S43 4JY. Alternatively you can drop your form in at one of our Contact Centres located in Bolsover, Clowne, Shirebrook or South Normanton.