Housing Benefit And Council Tax Support Claim Form Page 12

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Claim_rev 39
17/9/09
22:23
Page 12
Part 9 State benefits, pensions or allowances (continued)
About you
About your partner
Start date
Amount
Start date
Amount
/
/
/
/
Savings Pension Credit
£
£
ever y
ever y
/
/
/
/
Severe Disablement Allowance
£
£
ever y
ever y
/
/
/
/
State Pension
£
£
ever y
ever y
/
/
/
/
Statutory Paternity, Maternity
£
£
or Sick Pay
ever y
ever y
/
/
/
/
War Widow’s Pension or
£
£
Disablement Pension
ever y
ever y
/
/
/
/
Widow’s Pension or
£
£
Industrial Widow’s Pension
ever y
ever y
/
/
/
/
Working Tax Credit
£
£
ever y
ever y
/
/
/
/
Widow’s or Widower’s Benefit
£
£
ever y
ever y
I receive another benefit
(please give details)
/
/
/
/
£
£
ever y
ever y
I receive another benefit
(please give details)
/
/
/
/
£
£
ever y
ever y
I receive another benefit
(please give details)
/
/
/
/
£
£
ever y
ever y
Answer Yes or No
Answer Yes or No
Are you in the Mobility Scheme?
If you have used a separate sheet of paper, write ‘Part 9’ at the top of it, sign and date it and tick this box.
Lambeth Revenues and Benefits, Olive Morris House, 18 Brixton Hill, London, SW2 1RD
Page 12 of 32
Phone: 0845 300 0328
Website:

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