A Claim Form For Housing Benefit And Council Tax Support Page 3

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Part 1
About you and your partner
page 3
continued
You
Your partner
Do you or your partner get
No
No
Disability Living Allowance or
Yes
How much?
Yes
How much?
Personal Independence
Care
Care
£
£
Payment?
Mobility
Mobility
£
£
Do you or your partner get
No
No
Attendance Allowance?
Yes
Yes
Does anyone get Carer’s
No
No
Allowance for looking after
Yes
Yes
you or your partner?
Have you or your partner
No
No
been told that you are
Yes
Yes
entitled to Carer’s Allowance
even if you do not receive it,
because you are getting
another benefit instead?
Do you or your partner pay
No
No
towards the upkeep of a
Yes
How much do you pay and how often?
Yes
How much do you pay and how often?
student?
£
every
£
every
Do you or your partner have a
No
No
vehicle from a Mobility
Yes
Yes
scheme?
Are you or your partner a
No
No
student?
Yes
Tell us if this is full or part time.
Yes
Tell us if this is full or part time.
By student we mean anyone who
is attending a course of study at
an educational establishment
Full time
Part time
Full time
Part time
including student nurses.
How much of your income is
£
a year
£
a year
taken into account when
working out your grant?
Please tick if you or your
partner are:
• an apprentice
• on youth training
• in legal custody
• severely mentally impaired
• registered blind
• long-term sick or disabled
Are you being looked after by
No
No
Social Services?
Yes
Yes
If yes please give the date it
/
/
/
/
started
Are you entitled to Leaving
No
No
Care Support?
Yes
Yes
Do you or your partner have
No
No
a carer who stays overnight
Yes
Yes
with you?
If yes please tell us their name
We will contact you if we need any more information.

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