Housing And Council Tax Benefit Application - South Norfolk Council (Page 6 of 8) in pdf

Housing And Council Tax Benefit Application - South Norfolk Council Page 6

Part 3 –

Other Information

Date you want to claim benefit from

Backdating

We can usually award benefit from the Monday after the day we receive your claim. Sometimes we

can pay benefit from an earlier date if you have a good reason for not claiming earlier. If you want

us to consider paying your benefit from an earlier date, tell us when you want benefit from, and why

you did not claim benefit earlier.

During this earlier period, were your circumstances different to those you have

Y / N

told us about on this form?

Please tell us your reasons for any delay in making your application (Continue on a separate sheet

if necessary)

Notes/Additional information/Future Changes (Continue on a separate sheet if necessary)

Declaration

Please read this declaration carefully before you sign and date it.

•

I understand that this claim is made to you, my local council.

•

I declare that the information I have given on this form is correct and complete as far as I know and believe.

•

I understand that if I knowingly give information that is incorrect or incomplete, I may be liable to prosecution or

other action being taken.

•

I agree that you will use the information I have provided to process my claim for Housing Benefit or Council Tax

Benefit, or both. You may check some of the information with other sources as allowed by the law.

•

I understand that you may use any information I have provided in connection with this and any other claim for

state Benefit that I have made or may make. You may give some information to other organisations, such as

government departments, local authorities and private-sector companies such as banks and organisations that

may lend me money, if the law allows.

•

I know that I must let you know straight away about any changes in my circumstances which might affect my

claim. I understand that if I do not tell you about any changes and you pay me too much benefit because of

this, I may have to pay back the extra benefit.

•

I understand that I may be prosecuted if I do not tell you about any change of circumstances.

Please sign below

Print Name

Signature

Date:

Signature of Partner

Date:

Benefit Officer

Date:

Housing And Council Tax Benefit Application - South Norfolk Council Page 6

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