Housing Benefit And Council Tax Support Claim Form Page 4
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32Claim_rev 39
17/9/09
22:22
Page 4
Part 2 About you and your partner (continued)
About you
About your partner
Are you registered blind?
Answer Yes or No
Answer Yes or No
Does anyone get Carer’s Allowance for
Answer Yes or No
Answer Yes or No
looking after you?
If Yes, what is their name?
What is their relationship to you?
Do you get the care component of
Answer Yes or No
Answer Yes or No
Disability Living Allowance (DLA)?
Do you get the mobility component of
Answer Yes or No
Answer Yes or No
Disability Living Allowance (DLA)?
Do you get Attendance Allowance?
Answer Yes or No
Answer Yes or No
Are you on a New Deal, Welfare to
Work or other Department for
Answer Yes or No
Answer Yes or No
Work and Pensions scheme?
If Yes, please send proof.
Are you currently in hospital?
Answer Yes or No
Answer Yes or No
/
/
/
/
If Yes, what date did you go in?
/
/
/
/
What date do you expect to come out?
Are you going to return to your home?
Answer Yes or No
Answer Yes or No
Have you been unable to work
because of sickness for the past 52
Answer Yes or No
Answer Yes or No
weeks or more?
Are you severeIy mentally impaired?
Answer Yes or No
Answer Yes or No
Are you a student nurse?
Answer Yes or No
Answer Yes or No
Answer Yes or No
Answer Yes or No
Are you an apprentice?
Answer Yes or No
Answer Yes or No
Are you on youth training?
Answer Yes or No
Answer Yes or No
Are you in legal custody?
If Yes, are you on remand?
Answer Yes or No
Answer Yes or No
Answer Yes or No
Answer Yes or No
Have you been sentenced?
/
/
/
/
On what date were you remanded?
/
/
/
/
On what date were you sentenced?
What date do you expect to
/
/
/
/
be released?
Are you away from your home?
Answer Yes or No
Answer Yes or No
/
/
/
/
If Yes, since what date?
And for what reason?
Lambeth Revenues and Benefits, Olive Morris House, 18 Brixton Hill, London, SW2 1RD
Page 4 of 32
Phone: 0845 300 0328
Website:
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