A Claim Form For Housing Benefit And Council Tax Support

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Local authority office date stamp
Date form requested:
Name:
April 2013
Department:
Help notes can be found on pages 20 and 21.
You are still liable for your full rent and Council Tax until a decision has been made on your claim.
A claim form for Housing Benefit and
Council Tax Support
Are you (please tick one box)
Benefit Claim Reference
an owner/occupier?
a council tenant?
(if known)
a housing association or
a private tenant?
social landlord tenant?
Part 1
About you and your partner
Do you have a partner who normally lives with you?
No
Yes
If you have a partner, you must answer all the questions
about them, as well as yourself.
You
Your partner
Surname or family name
Other names
Tell us the other names
Tell us the other names
Have you ever used any
No
No
other names?
Yes
Yes
Title (Mr, Mrs, Ms, other)
Status Please tell us if you are
single, married, in a civil
partnership, divorced, legally
separated, widowed, etc
Address including room
number if you have one
Do not tell us your partner’s
address if it is the same as
yours.
Postcode
Postcode
Email:
Email:
What date did you move to
/
/
/
/
this address
Your daytime phone number
Code
Number
Code
Number
What is this number?
Home
Work
Mobile
Textphone
Home
Work
Mobile
Textphone
Please tick.
/
/
/
/
Date of birth
Letters
Numbers
Letter
Letters
Numbers
Letter
National Insurance number
(NI no) You can find this on
payslips or letters from social
If you do not have a NI no. or cannot
If your partner does not have a NI no.
security or the tax office. We
find it, tick this box.
or cannot find it, tick this box.
cannot normally decide your claim
if we do not have your NI no.
Do you receive or have you
No
No
applied for Income Support,
Yes
Yes
Guarantee Credit, income
based Job Seeker’s Allowance
or income based Employment
We need to see proof of your identity and NI number. See the checklist at Part 15.
Support Allowance?

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