Housing Benefit And Council Tax Support Claim Form Page 11

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Claim_rev 39
17/9/09
22:23
Page 11
Part 9 State benefits, pensions or allowances
We need to see proof of any state benefits, pensions or allowances you and your partner get, such as a letter from
Proof
Jobcentre Plus, HM Revenue & Customs, The Pension, Disability and Carers Service or Department for Work and Pensions.
needed
If you have applied for any of the benefits or pensions listed below but are not receiving them yet, write ‘Applied’ in the
box with the £ sign. If you are getting any of them, put in the amount and how often you receive it.
If you need more space, use an extra sheet of paper and attach it to this form.
About you
About your partner
Are you getting any
Answer Yes or No
Answer Yes or No
pensions or benefits?
Are you waiting to hear about
Answer Yes or No
Answer Yes or No
any pensions or benefits?
If you have answered No to the questions above for both you and your partner, go straight to part 10.
Please say if you are getting any of the following benefits. We must see proof of any you get.
Start date
Amount
Start date
Amount
/
/
/
/
Bereavement Allowance
£
£
ever y
ever y
/
/
/
/
Carer’s Allowance
£
£
ever y
ever y
/
/
/
/
Child Benefit
£
£
ever y
ever y
/
/
/
/
Child Tax Credit
£
£
ever y
ever y
/
/
/
/
Contribution-based
£
£
Employment and Support Allowance
ever y
ever y
/
/
/
/
Contribution-based
£
£
Jobseeker’s Allowance
ever y
ever y
/
/
/
/
Foster or adoption allowance
£
£
ever y
ever y
/
/
/
/
Guardian’s Allowance
£
£
ever y
ever y
/
/
/
/
Incapacity Benefit
£
£
ever y
ever y
/
/
/
/
Industrial Death Benefit
£
£
ever y
ever y
/
/
/
/
Industrial Injuries Disablement Benefit
£
£
ever y
ever y
/
/
/
/
Maternity Allowance
£
£
ever y
ever y
Lambeth Revenues and Benefits, Olive Morris House, 18 Brixton Hill, London, SW2 1RD
Page 11 of 32
Phone: 0845 300 0328
Website:

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