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

Discretionary Housing Payment Application Form Page 6

Discretionary payments are only usually awarded for a limited period – if you were successful, for what

21)

period do you wish to claim this extra help?

From:

To:

What steps will you be taking to meet the shortfall of your rent after any successful award ceases?

22). Are there any other circumstances that you would like the Council to consider when assessing whether

you would qualify for Discretionary Housing Payment? If there are, please give circumstances below.

Finally, whether your application is successful or not, the Housing Options team (located within the Housing

Department) may be able to help you with certain aspects of your tenancy (such as negotiating with your Landlord),

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or the Un Sir

team at The Hub may be able to refer you for training, employment or money advice. There may be

instances where the Benefits Section feels you would benefit from advice from these teams- in such an event would

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you be willing for the Benefits Section to refer your details to the Housing Options advisor or the Un Sir

Hub?

Yes

If yes, please sign in the following box to provide authorisation for the Benefits Section to refer your details.

Signature

DECLARATION - TO BE COMPLETED BY ALL APPLICANTS

I Declare that the information given is to the best of my knowledge correct and I agree to inform the Housing Benefit Section as

soon as any details change. The Council may make enquiries to check any information.

Under the terms of the Data Protection Act, 1984, information supplied will be treated in confidence but may be used for

registrated purposes.

Signed _____________________________________Date_______________________________________

............

IF YOU DELIBERATELY GIVE FALSE INFORMATION YOU MAY BE PROSECUTED

Claim ref:

Discretionary Housing Payment Application Form Page 6