Housing Benefit And Council Tax Support Claim Form Page 7
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32Claim_rev 39
17/9/09
22:23
Page 7
Part 4 Other people who live with you (continued)
Person 1
Person 2
Person 3
Are any of the people in your
Answer Yes or No
Answer Yes or No
Answer Yes or No
household married or living
together as if they were married?
If Yes, please fill in the following.
is the partner of
is the partner of
or
Is anyone in legal custody at the
Answer Yes or No
Answer Yes or No
Answer Yes or No
moment?
If Yes, are they on remand?
Answer Yes or No
Answer Yes or No
Answer Yes or No
Answer Yes or No
Answer Yes or No
Answer Yes or No
Have they been sentenced?
On what date were they remanded or
/
/
/
/
/
/
sentenced?
On what date do they expect to be
/
/
/
/
/
/
released?
Is anyone in hospital at the moment?
Answer Yes or No
Answer Yes or No
Answer Yes or No
If Yes, on what date do you expect
/
/
/
/
/
/
them to come out?
Is anyone providing care for someone
Answer Yes or No
Answer Yes or No
Answer Yes or No
in your home for more than 35 hours a
week?
is caring for
If Yes, who is caring for who?
is caring for
If you have used a separate sheet of paper, write ‘Part 4’ at the top of it, sign and date it and tick this box.
Part 5 Income Support, income-based Jobseeker’s Allowance,
income-related Employment and Support Allowance and Guarantee Pension Credit
This part is about Income Support, income-based Jobseeker’s Allowance, income-related Employment and Support
Proof
Allowance and Guarantee Pension Credit you and your partner receive. We must see proof of any benefits you get,
needed
such as a recent benefit entitlement letter or letter from The Pension, Disability and Carers Service.
About you
About your partner
Are you getting Income Support,
income-based Jobseeker’s Allowance,
income-related Employment and
Answer Yes or No
Answer Yes or No
Support Allowance or
Guarantee Pension Credit?
/
/
/
/
If Yes, when did you start receiving it.
Go to part 13 if you or your partner have answered Yes to the question above.
Are you waiting to hear about a claim
for Income Support, income-based
Jobseekers’ Allowance, income-related
Answer Yes or No
Answer Yes or No
Employment and Support Allowance or
Guarantee Pension Credit?
/
/
/
/
If Yes, when did you make the claim?
Lambeth Revenues and Benefits, Olive Morris House, 18 Brixton Hill, London, SW2 1RD
Page 7 of 32
Phone: 0845 300 0328
Website:
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