Discretionary Housing Payment Application Form (Page 4 of 6) in pdf

Discretionary Housing Payment Application Form Page 4

About your family – all claimants must answer this section.

16). Does anyone in your family need extra care or

Yes

support because they are sick, elderly or disabled?

a) do you need an extra bedroom for a

Yes

non resident carer?

If yes, please provide details of who provides the care, how often this is provided and if you have a doctors

letter or formal care plan that would confirm these arrangements.

b) do you need an extra bedroom for a disabled child?

Yes

if yes, please confirm why this extra room is needed – we may also write to you for more information.

c) do you need an extra room because you and your partner are unable to share a bedroom due to your

disabilities?

Yes

If so, please provide a letter from your doctor to confirm this.

17). Has the number of occupants in your household

…Yes

changed in the last 12 months due to a bereavement?

If ‘yes’ please give details..

18)

Do you or your partner receive any of the following?

Disability Living Allowance

Mobility Allowance

Yes

Attendance Allowance

A war pension

Yes

Personal Independence Payments

Yes

…Yes

19)

Are you a registered Foster Carer?

If yes, do you

currently have any resident foster children?

Yes

If so, how many bedrooms do you need to accommodate the foster children.

If you have more than one foster child and they cannot share a bedroom please tell us why they cannot share

If you do not currently have any resident Foster children are you keeping an extra room available because

…Yes

you are in between foster children?

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

Discretionary Housing Payment Application Form Page 4