Housing Benefit And Council Tax Support Claim Form (Page 15 of 18) in pdf

Part L

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, getting them to sign this form should allow us to process your claim more quickly, but they do not have

to sign. Please read this declaration carefully before you sign and date it.

• The information I have given on this form is correct and complete as far as I know and believe.

• I understand that if I knowingly give information or evidence that is incorrect, incomplete or false, I may be

liable to prosecution or other action.

• I agree that you will use the information I have provided to process my claim for Housing Benefit or Council

Tax Support, or both. You may check some of the information with other sources as allowed by the law.

• I understand that 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 that I must tell the Benefits Service of my Local Authority in writing straight away about any change

in my circumstances which might affect my claim. Some examples of changes you must tell us about are

given below (if you are not sure if a change may affect your claim please tell us anyway):

• If you rent your home, from somebody other

• If the income of anyone in your household goes

than the council, any changes to your rent or

up or down

conditions of tenancy

• If a child leaves school or Child Benefit stops

• If you change address, even to another room in

• If you or your partner’s income goes up or down

the same house

• If you or your partner’s savings or investments go

• Absence from your home for more than 13 weeks

up or down

• Tax Credit changes

• If you or your partner make a claim for Universal

• If you or your partner start working or change

Credit, or

employer

• If you or your partner come off Income Support,

• If you or your partner have a baby

Jobseeker’s Allowance, Employment and

• If anyone joins or leaves your household

Support Allowance, Universal Credit.

Signature of person claiming

Date

Partner’s signature

Date

The section below must be filled in if someone has filled in the claim form for you.

This includes an agent, appointee, relative or friend.

I have filled in this form on behalf of

As they cannot fill in the form because

I am (block capitals)

Relationship to 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

Signature of the person

Date

Page 15

Housing Benefit And Council Tax Support Claim Form Page 15

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