A Claim Form For Housing Benefit And Council Tax Support Page 5
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28Part 3
About other people who live with you
page 5
Now tell us about all the people who usually live with you and your partner, including people who just share a hall, bathroom or
toilet with you. If you want to tell us about more than three people, use a separate sheet of paper.
If you are sending a separate sheet of paper, tick this box.
No
Go to Part 4.
Do any adults usually live with you and your partner?
Yes
Fill in this section.
By adults we mean people over 16 who nobody gets Child Benefit for. Some examples are aunt, brother, daughter, father, grandson,
grandmother, stepdaughter, cousin, ex-partner, ex-husband, joint tenant, landlord, landlord’s partner, joint owner, subtenant, lodger, boarder,
carer, appointee, friend, acquaintance, visitor, or person from abroad. This is not a full list, and we need to know about all adults who live with
you.
First person
Second person
Third person
Last name
Other names
Date of birth
/
/
/
/
/
/
National Insurance Number
Their relationship to you or
your partner
When did they move in?
/
/
/
/
/
/
Do they get Income
No
No
No
Support or income-based
Yes
Yes
Yes
Jobseeker’s Allowance?
Do they get Disability
No
No
No
Living Allowance, Personal
Yes
How much?
Yes
How much?
Yes
How much?
Independence payment or
Attendance Allowance?
£
a week
£
a week
£
a week
Are they registered blind?
No
No
No
Yes
Yes
Yes
Are they a full-time student,
No
No
No
a student nurse, a care
Yes
Tell us which.
Yes
Tell us which.
Yes
Tell us which.
worker, an apprentice or on
youth training?
Do they pay rent or money
No
No
No
for board and lodgings to
Yes
How much?
Yes
How much?
Yes
How much?
you or your partner?
£
a week
£
a week
£
a week
No
No
No
Does this include money for
food?
Yes
Yes
Yes
No
No
No
Does this include money for
heating?
Yes
Yes
Yes
No
No
No
Are they severely mentally
impaired?
Yes
Yes
Yes
Are they in legal custody
No
No
No
at the moment?
Yes
When are they due
Yes
When are they due
Yes
When are they due
to come out?
to come out?
to come out?
/
/
/
/
/
/
Are they in hospital at
No
No
No
the moment?
Yes
Tell us about it below
Yes
Tell us about it below
Yes
Tell us about it below
When did they go in?
/
/
/
/
/
/
When are they due to come
/
/
/
/
/
/
out (if you know)?
Do they normally work for
No
No
No
16 hours or more a week?
Yes
Tell us their earnings before
Yes
Tell us their earnings before
Yes
Tell us their earnings before
any deductions.
any deductions.
any deductions.
£
£
£
We need to see proof of their
We need to see proof of their
We need to see proof of their
earnings.
earnings.
earnings.
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