A Claim Form For Housing Benefit And Council Tax Support Page 26

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What type of accommodation are you providing for this tenant?
Detached House
Semi-Detached House
Terraced House
Flat in House
Flat over Shops
Flat in Block
Maisonette
Bungalow
Hostel
Room or Rooms
Something else
Please say what
Please tell us the number of floors in the whole building
What floor does the tenant live on? All Floors
Basement
Ground
1st
2nd
Other
(please say which)
If the tenant has sole occupation of only one room, please indicate its location on the floor in the building:
Front
Centre
Rear
Does the tenant have to share a bedroom?
Yes
No
If YES, who do they share with?
How many rooms are in the
Single
Double
Bed
Living
Dining
Bath
Kitchen
Toilet
Other
property?
Bedsit
Bedsit
rooms
Rooms
Room
room
Total number of rooms
Rooms that only your tenant uses
Rooms that your tenant shares
If the rent includes any of these please tick 3the box and give the amount charged per week.
Water Rates
Heating
Garage/Parking
Lighting
Council Tax
Hot Water
Laundry
Fuel for Cooking
Cleaning
Garage
Does the accommodation have central heating? Yes
No
Yes
No
Are meals included? If YES, which ones? Breakfast
Lunch
Dinner
Declarations
Please read these statements carefully, sign and date the form and then return it to The Benefits Section at Slough Borough Council.
HOUSING BENEFIT WILL NOT BE PAID WITHOUT THIS INFORMATION.
YOU MUST READ THIS
REMEMBER: If you deliberately give false or incomplete information you are likely to be prosecuted under the Social Security Administration
(Fraud) Act 1997.
• I declare that the information given on this form is true and complete.
• I agree that the Council make any necessary enquiries to check the information on this form.
• I agree to inform the Benefits Section of Slough Borough Council immediately if any of the information I have given on this form changes.
• I confirm that the information provided is true and complete and I understand that I may be prosecuted if I state something which I know
to be false or do not believe to be true.
Landlord’s/Agent’s Signature:
/
/
Date:
/
/
Name in BLOCK CAPITALS:
Date:

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