Discretionary Housing Payment Application Form (Page 2 of 6) in pdf

Discretionary Housing Payment Application Form Page 2

6) Is the shortfall due to any of the following reasons (please tick the relevant box)

Single and aged between 25 and 35 (private tenants only)

Local Housing Allowance rate does not meet the asking rent

Reduction in benefit due to the Social Sector Size Criteria (known as Bedroom tax)

(Housing Association and Local Authority tenants only)

Benefit Cap

For persons renting from a private landlord only

?…

…Yes

7a)

Have you tried to negotiate a lower rent with your landlord

If ‘yes’, please provide written proof of the outcome of this negotiation, if no proof available please state below

what was the result of the negotiation

If ‘no’, please give your reasons why you have not negotiated a lower rent with your landlord and provide details of

what contact you have made regarding this matter.

…Yes

7b)

Do you require assistance to negotiate with your landlord?

If yes, please provide contact details for your landlord and sign this box to confirm that you authorise this

department to contact the landlord on your behalf.

Signature

8) Have you recently moved to this property within the last 6 months

Yes

If no, please go to question 11, about your home

If yes please answer the following:

Why did you leave your previous address?

9).Did you make enquiries as to how much help you would receive at this address before moving in?

Yes

If not, why not?

If yes, please explain why you took on this tenancy knowing that there would be a shortfall to pay

Claim ref: ............

Discretionary Housing Payment Application Form Page 2