Housing Benefit and Council Tax Benefit claim form

BENEFITS CLAIM FORM
Housing Benefit and Council Tax Benefit
The Benefits Service
The Town Hall
Hornton Street
W8 7NX
020 7361 3025
REF
DATE
REASON
Office Use Only
The New Claim Team can help you fill in this form. If you have problems reading or
understanding this form, or want to know what proof you must provide, call 020 7361 3025.
Part 1 About you and your partner
Check what proof we need on page 20 Part 1
By partner we mean your husband or wife or someone you live with as if you were married or civil partners.
Do you have a partner
Yes
No
If No, ignore all the questions about your partner.
First names
You
Mr Mrs Miss Ms
First names
Your partner
Mr Mrs Miss Ms
Surname
Surname
Any other names you have used or are known by
Any other names you have used or are known by
Date of birth
/ /
National Insurance number
Letters Numbers Letter
Date of birth
/ /
National Insurance number
Letters Numbers Letter
Daytime telephone number
Daytime telephone number
Your address you are claiming for – include the flat or room number
Postcode
1

Part 1
About you and your partner
You
Check what proof we need on page 20 part 1
Your partner
Have you or your partner
claimed Housing Benefit or
Council Tax Benefit before
No
Yes
When did you claim
No
Yes
When did they claim
/ /
/ /
What council did you claim from
What council did they claim from
What name did you claim in
What name did they claim in
What address did you claim for
What address did they claim for
Postcode
Postcode
If you have moved home in
the last 12 months, tell us
your last address.
Postcode
Postcode
Were you the home owner,
private tenant, council tenant
or boarder at this address
What is your nationality
If your nationality is not
British, what date did you
enter the UK
The UK is England, Northern
Ireland, Scotland and Wales.
/ / / /
Are you or your partner in
hospital at the moment
No
Yes
When did you go in
No
Yes
When did they go in
/ /
/ /
When do you expect to come out
(if you know this)
/ /
When do you expect to come out
(if you know this)
/ /
2

Part 1
About you and your partner – cont.
You
Check what proof we need on
page 20 part 1
Your partner
Do you or your partner get
Disability Living Allowance
No
Yes
How much
No
Yes
How much
Care: £
Care: £
Mobility: £ Mobility: £
Do you or your partner get
Attendance Allowance
No
Yes
No
Yes
Does anyone get Carer’s
Allowance for looking after
you or your partner
No
Yes
No
Yes
Have you or your partner ever
claimed Carer’s Allowance
No
Yes
No
Yes
Still tick ‘Yes’ if you were not paid any Carer’s Allowance. This could have been because you were
better off getting another social security benefit.
Do you or your partner pay
towards the upkeep of a
student
No
Yes
How much do you pay
No
Yes
How much do they pay
£
£
How often
Every
How often
Every
Do you or your partner have
a vehicle from a Mobility
scheme
No
Yes
No
Yes
Are you or your partner a
student
No
Yes
No
Yes
Do you study full time or part time
Do they study full time or part time
Please tick if you or your
partner are:
Full time Part time Full time Part time
• an apprentice
• on youth training
• in legal custody
• severely mentally impaired
• registered blind
• long-term sick or disabled
3

Part 2
About children
Check what proof we need on page 20 part 2
We need to know about any children in your household if they are:
• under 16;
• aged 16 or 17 and registered for work or youth training; or
• in education doing a course not higher than GCE A-level, SCE Higher level or GNVQ (advanced).
Are there any children in your household
No
Go to Part 3.
Yes
If there are more than 3 children, use a separate sheet of paper
to tell us all the information we ask for on this page.
If you are sending a separate sheet of paper, tick this box.
First child
Second child
Third child
First name
Surname
Date of birth
/ /
/ /
/ /
What is the child’s sex
The child’s relationship to you
The child’s relationship to
your partner
Usual address if different
from yours
Child Benefit number
Who gets the Child Benefit
for them
We need to see proof of this.
Is the child registered blind
No
No
No
Yes
Yes
Yes
We need to see
evidence of this.
We need to see
evidence of this.
We need to see
evidence of this.
Does the child get Disability
Living Allowance
No
Yes
How much
No
Yes
How much
No
Yes
How much
Care: £
Care: £
Care: £
Mobility: £ Mobility: £ Mobility: £
4

Part 2
About children – cont.
Check what proof we need on page 20 part 2
First child Second child Third child
Do you pay a registered
childminder, nursery or
after-school club any
childminding costs for this
child
No
Yes
No
Yes
If Yes, please complete the Certificate of Childcare expenses attached to
the back of this form.
No
Yes
Part 3
Other people who live with you
Check what proof we need on page 20
Part 3
Do any adults normally live
with you and your partner
By adults we mean people
over 16 who nobody gets
Child Benefit for.
No
Yes
Go to Part 4.
Give details below.
If you want to tell us about more than 2 people, use a separate sheet of paper.
If you are sending a separate sheet of paper, tick this box.
First person
Second person
First name
Surname
Date of birth
/ /
/ /
Their relationship to you
or your partner
Some examples are aunt, brother, daughter, father, grandson, grandmother, stepdaughter, joint tenant, joint
owner, subtenant, lodger or friend.
Do they get Income Support
or income-based
Jobseeker’s Allowance
No
Yes
No
Yes
Do they get Disability Living
Allowance, Attendance
Allowance or Pension
Credit
No
Yes How much
£ a week
No
Yes How much
£ a week
Are they registered blind
No
Yes
No
Yes
Are they a full-time student,
student nurse, care worker,
apprentice or on youth
training
No
Yes
Tell us which.
No
Yes
Tell us which.
5

Part 3 Other people who live with you – cont.
First person
Check what proof we need on
page 20 part 3
Second person
Do they pay rent or money
for board and lodgings to
you or your partner
No
Yes
How much
No
Yes
How much
£ a week
£ a week
Are they severly mentally
impaired
No
Yes
No
Yes
Are they in legal custody
at the moment
No
Yes
When are they
expected to
come out
No
Yes
When are they
expected to
come out
/ / / /
Are they in hospital at
the moment
No
Yes
When did they
go in
No
Yes
When did they
go in
/ / / /
When will they come out
(if you know this)
When will they come out
(if you know this)
/ /
/ /
Do they normally work
for 16 hours or more a
week
No
Yes
Tell us their
earnings
before any
deductions.
No
Yes
Tell us their
earnings
before any
deductions.
£ £
We need to see evidence
of their earnings.
We need to see evidence
of their earnings.
Do they have any other
income at all
This includes any benefits
or allowances you have not
told us about on this form
and interest from saving and
investments.
No
Yes
Name of
income
How much is it before deductions
Name of
income
How much is it before deductions
£ a week £ a week
Name of other income
No
Yes
Name of other income
How much is it before deductions
How much is it before deductions
£ a week £ a week
6

Part 3 Other people who live with you – cont.
First person
Name of third other income
Check what proof we need on
page 20 part 3
Second person
Name of third other income
How much is it before deductions
How much is it before deductions
£ a week £ a week
We need to see evidence of
other incomes.
We need to see evidence of
other incomes.
Are any of these people you
have told us about married to
each other, civil partners, or
living together as if they are
married or civil partners
No
Yes
And
Tell us their names.
is the
partner of
is the
partner of
Part 4 Rent Details
Check what proof we need on page 20 part 4
Do you rent your home No Go to Part 6, Page 11
Yes
Answer the next question
Are you living away from
home at the moment
No
Yes
Tell us why you are not living at home.
When did you last live at home
/ /
When do you expect to go back home
/ /
Tell us the address of where you are living at the moment.
Postcode
If your home has been sublet, tell us who lives there now.
7

Part 4 Rent Details – cont.
When did you start paying
rent
When did you move to
this address
Check what proof we need on page 20 part 4
/ /
/ /
If you have not moved in yet, tell us when you expect to move in, then tell us when you have actually moved in.
Do you pay rent to the
council
What is your landlord’s full
name and business address
No
Yes
Name
Address
Answer the questions below.
What is your reference number
Go to Part 6, Page 11
Postcode
Phone Number
If your landlord has an agent,
tell us their full name and
address.
Name
Address
Postcode
Phone Number
Are you, your partner, or any of your or your partner’s children related to your landlord or agent, or to your
landlord’s partner or the agent’s partner
Related includes related through marriage, even if the marriage has ended. Some examples are ex-wife, exhusband,
aunt, brother, daughter, father, grandson, grandmother, son-in-law or stepdaughter.
No
Yes
What is the
relationship
is my landlord’s
or agent’s
What sort of tenancy
do you have
E.g. assured shorthold.
How long is the tenancy for
/ / to
/ /
Please tick to show if the
property is let as:
furnished partly furnished minimally furnished unfurnished
How much is the rent for
your home £
Every
Does anyone else share the
rent with you and your
partner
No
Yes
Tell us their names and relationship to you and your partner.
How much of the shared rent do you pay
£
Every
8

Part 4 Rent Details – cont.
Check what proof we need on page 20 part 4
Has your rent been registered
as a fair rent by a rent officer
No
Yes
Please send us the notice of registration (RO5).
Do you have any weeks when
you do not have to pay rent
No
Yes
How many in a year
Are you behind with the rent
No
Yes
By how many weeks
Who receives the Council Tax
bill for your home
You or your partner
Someone else
Please give
details
Does your rent include money for:
Water Rates
No
Yes
How much each week
£
Heating
No
Yes
£
Lighting
No
Yes
£
Hot Water
No
Yes
£
Fuel for Cooking
No
Yes
£
Personal Laundry
No
Yes
£
Please list any other services eg.
Nursing, Warden, Alarm System, Lift,
Cleaning, Shared Services.
£
£
£
Does your rent include
money for meals No Yes Breakfast Lunch Evening Meal
Are you a Housing
Association tenant
No
Yes
Go to Part 6.
What type of accommodation do you live in
Flat in a block
Flat in a house
Studio flat
Hotel
Hostel
Maisonette
Other - Please describe eg. dormitory, bed-sit, care-home, caravan:
Terraced
house
Detached
house
9

Part 5 About where you live
Check what proof we need on page 20 part 4
We need to know about the different types of rooms in your home.
Number of rooms at your address
Bedrooms Bedsitting
rooms
Living
rooms
Kitchens Bathrooms Toilets
Other rooms
(please say what)
Number of rooms only used by
you & your family
Number of rooms you & your
family share with other people
Do you use your home
for business
No
Yes
Do you have another
home anywhere else
No
Yes
What is the address
You need to prove you live in the property & pay rent. Provide any of the following ORIGINAL documents:
• Tenancy agreement • Rent book or rent receipts • Letter from your landlord
The proof must show:
• The name & address of your landlord/agent • How much the rent is • Any services included in the rent
If you’re a private tenant & moving & want to know if your rent will be restricted phone 020 7361 3006 & ask
for advice. Otherwise call into the Town Hall or visit our website www.rbkc.gov.uk
10

Part 6 About being self-employed
Check what proof we need on page 20 part 6
Are you or your partner
self-employed
No
Yes
Go to Part 7.
What kind of work do you
do
You
Your partner
When did the business start
What is the business
address
/ /
/ /
Postcode
Postcode
Are there any other partners
in the business
No
Yes
Tell us their name
and address.
No
Yes
Tell us their name
and address.
Postcode
Postcode
How many hours a week
do you usually work
Do you get a Business
Start-up Allowance
No
Yes
How much
No
Yes
How much
£
£
How often
Every
How often
Every
Do you pay into a private
pension scheme
No
Yes
How much
No
Yes
How much
£
£
How often
Every
How often
Every
11

Part 7 About working for an employer
Check what proof we need on page 20 part 7
Do you or your partner work
for an employer No Go to Part 8.
Yes
Answer the questions on this page. If you work for more than
one employer, tell us about all the employers on a separate
sheet of paper and send it with this form.
If you are sending a separate sheet of paper, tick this box.
What kind of work do you
do
You
Your partner
What is your employer’s
name and address
When did you start this job
What is your payroll,
employee or staff number
Postcode
/ /
Postcode
/ /
Are you employed for a
limited period
No
Yes
When will you finish
No
Yes
When will they finish
/ / / /
How much do you get paid
before Tax and National
Insurance are taken off
£ £
How often do you get paid Every Every
How are you paid
For example, in cash, by
cheque or straight into a bank
or building society account.
When was your last pay rise / /
/ /
When is your next pay rise
/ /
/ /
How many hours a week do
you usually work
Give details of any regular
overtime, bonuses or
commission.
Are you getting Statutory
Sick Pay or Statutory
Maternity Pay from
your employer at the
moment
No
Yes
No
Yes
12

Part 7 About working for an employer
You
Check what proof we need on page 20 part 7
Your partner
Are you getting any other
sickpay or maternity pay
from your employer at the
moment
No
Yes
No
Yes
Do you pay into a private or
company pension scheme
No
Yes
No
Yes
How much
£
How much
£
Every
Every
Part 8 About any other work
Check what proof we need on page 20 part 7
Do you or your partner do
any other work at all
This could be voluntary work
or any other work, even if it is
not paid work.
No
Yes
Go to Part 9.
Answer the questions on this page.
You
Your partner
What other work do you do
What is the name and address
of the person you do this
work for
Postcode
Postcode
When did you start this work
/ /
/ /
How many hours a week do
you usually work
Do you get paid
If you only get expenses or tips,
still tick ‘Yes’ and give details
No
Yes
How much do you get
before any deductions
No
Yes
How much do they get
before any deductions
£
£
How often
Every
How often
Every
We must see evidence of any earnings before we can decide how much benefit you can get.
Read the checklist on Page 20 to see what you can use as evidence.
13

Part 9 About Income Support, income-based Jobseeker’s Allowance
and Pension Guarantee Credit
Are you or your partner still
waiting to hear about
a claim for Income Support,
income-based Jobseeker’s
Allowance or Pension
Guarantee Credit
No
Yes
You
When did you claim
/ /
Check what proof we need on page 20 part 7
No
Yes
Your partner
When did they claim
/ /
Are you or your partner
actually getting Income
Support, income-based
Jobseeker’s Allowance or
Pension Guarantee Credit at
the moment
No
Yes
Go to Part 10.
Go to Part 12.
When did you start
getting it
No
Yes
Go to Part 10.
Go to Part 12.
When did they start
getting it
/ /
/ /
Part 10 About benefits and pensions
Check what proof we need on page 20 part 7
Are you or your partner getting any benefits or waiting to hear about benefits you have claimed
No
Go to Part 11.
Yes
Tell us about the benefits below. Tell us the full rate of the benefits before
any deductions.
This is a list of the most common benefits. If your benefit is not shown you must still give us details below
• Bereavement Allowance
• Child Benefit
• Child Tax Credit
• Fostering Allowance
• Guardian Allowance
• Incapacity Benefit
• Industrial Injuries Disablement Benefit
• Industrial Death Benefit
• Carer’s Allowance
• Employment & Support Allowance
• Contribution-based Jobseeker’s Allowance
• Maternity Allowance
• Pension Credit
• Retirement Pension
• Severe Disablement Allowance
• War Disablement Benefits, War Pension or
War Widow’s Pension
• Widow’s or Widower’s Benefits
• Working Tax Credit
• Statutory Sick Pay or Statutory Maternity Pay
You
Your partner
The name of the benefit
or pension
Are you waiting to hear
No
Yes
No
Yes
Are you getting it now
No
Yes
No
Yes
How much
How much
£
£
How often
How often
Every
Every
14

Part 10 About benefits and pensions
You
Check what proof we need on page 20 part 10
Your partner
The name of the benefit
or pension
Are you waiting to hear
No
Yes
No
Yes
Are you getting it now
No
Yes
No
Yes
How much
How much
£
£
How often
How often
Every
Every
Part 11 About other money coming in
Check what proof we need on page 20 part 7
Do you or your partner have any money coming in (or expect to have some money) that you have not
already told us about. This might include: occupational pension, student loan, rental income, money from a
trust fund, maintenance, child support, training allowance etc.
No
Yes
Go to Part 12.
Answer the questions below
Other money 1
What is the money for
Who gets it
How much do they get
How often
£
Every
When did they start getting
this income
When is the income likely
to go up
/ /
/ /
15

Part 11 About other money coming in
Check what proof we need on page 20 part 7
Other money 2
What is the money for
Who gets it
How much do they get
How often
£
Every
When did they start getting
this income
When is the income likely
to go up
/ /
/ /
Does anyone owe money to
you, your partner, or any
children you are claiming for
No
Yes
What for
How much
£
Are you expecting to get any
money in the next 12 months
For example, a redundancy
payment or a payment instead
of notice or holiday.
No
Yes
What for
How much
£
Part 12 About accounts, savings and investments
Check what proof we need
on page 20 part 7
Accounts, savings and investments include:
• All accounts even empty or overdrawn
• Bank Accounts
• Building Society Accounts or Passbooks
• Current Accounts and Deposit Accounts
• Post Office Accounts
• Savings Accounts
• Investment Accounts
• ISAs, TESSAs or TOISAs
• Stocks, Shares, Bonds or unit trusts
• Property ownership (here and abroad)
• Land ownership (here and abroad)
16

Part 12 About accounts, savings and investments
Check what proof we
need on page 20 part 7
Do you or your partner have
any accounts or savings
No
Yes
Tell us about all your accounts.
Name of bank, building society etc. Account number, name, type Account balance
£
£
£
£
£
If there are more than 6 accounts, tell us about the others on a separate sheet of paper.
If you are sending a separate sheet of paper, tick this box.
£
Do you or your partner have any
premium bonds, National Savings
Certificates or Stocks, Shares,
Bonds or unit trust
No
Yes
Tell us about them.
Details of bonds, Shares etc. Number of shares, Issue date etc. Value
£
£
£
£
Do you or your partner own or partly
own any property, land or timeshare,
either in the UK or abroad
Tick “Yes” even if you have a mortgage
or loan for the property, land or
timeshare.
No
Yes
What is the address
Postcode
17

Part 12 About accounts, savings and investments
How much is it worth
Check what proof we need
on page 20 part 7
If you have a mortgage or loan, how much is left to pay
£
£
Have you declared all the accounts,
savings and investments that you and
your partner have
No
Yes
If “No” give details
Part 13 How your benefit is paid
Council Tax Benefit is sent to the council tax account.
Council Tenants’ Housing Benefit is sent to their rent account.
Housing Association Tenants can choose who receives their Housing Benefit by answering the questions below.
Private Tenants renting from private landlords, have their Housing Benefit sent to their bank or savings
account. Landlords can be paid directly but in addition to answering the questions below you need to explain
why you do not want to receive your benefit payments in Part 14. Your request will be considered on its merits.
I want benefit paid to my account
Complete the details below.
I do not have a bank account
I want benefit paid to my landlord’s account
Complete the details below and if you are a private tenant
you must explain why your landlord is to be paid in Part 14.
Name of bank or building society
Address
Postcode
Whose name is the account in
Account number
Sort code
Part 14 Anything else you want to tell us
Use the box below to tell us anything else you think we should know about. Use a separate sheet of paper and
attach it to this form if you need to.
18

Part 15 Backdating
We usually pay benefit from the Monday after we receive your claim. Sometimes we can pay from an earlier
date if you have a good reason for not claiming earlier.
Date you want to claim benefit from
/ /
Tell us why you have not claimed earlier.
Part 16 Declaration
THIS MUST BE SIGNED. If you do not sign this part of the form, it may delay payment on your claim. Even if someone
else has filled in this form for you, you must sign this declaration if you can.
If you have a partner, it would be helpful if they sign below to confirm all the details about them are
correct. But they do not have to sign.
Please read this declaration carefully before you sign and date it.
I understand the following.
• If I give information that is incorrect or incomplete, you may take action against me. This may include court action.
• You will use this 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 my other sources as allowed by the law.
• You may use any information I have provided in connection with this and any other claim for social security benefits that
I have made or may make. You may give some informaton 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 this.
I know I must let the Benefits Service know about any change in my circumstances which might affect my claim.
I declare the information I have given on this form is correct and complete.
Signature of the person
claiming
Date
/ /
Partner’s signature
Date
/ /
Has this form been filled in by someone other than the person claiming
Please tell us why you are filling in this form for the person claiming.
If aged less than 18 give date of birth.
No
/ /
Yes
As far as possible, I have asked all the questions on the form. The claimant has understood the questions and I have
confirmed with the person claiming that the answers I have written on this form are correct.
Name of the person who
filled in the form
Signature of the person
Relationship to the person
making the claim
Date
/ /
19

Evidence You MUST Supply
Most claims are not paid because we don’t have enough evidence. Below we say what you
need to supply. If you cannot supply proof or have any questions phone 020 7361 3025 or
call into the Town Hall where the Benefits New Claim Team will help you.
Part 1 – Everyone must prove their Identity and National Insurance Number
We must see ORIGINAL evidence of you & your partner’s identity & National Insurance Number. The
following can be used to prove identity: Birth Certificate, Passport, EEA Identity Card, Driving Licence, Letter
from DWP, Current Bank Statement, Home Office Letters.
National Insurance Number (NINO)
Your NINO will be on wage slips, P45 or P60, Tax Credit letter, Pension Service letter, DWP letter.
Evidence of Disability Benefit
Letter from DWP or bank statement showing award.
Students – provide an original letter from your college or university confirming the official course title, term
dates and detail if the course is full or part-time.
Part 2 – Evidence if you have children
We must see ORIGINAL evidence of who receives child benefit.
If you pay a registered childminder, nursery or after-school club send in details & expenditure. There is a form that
you can complete at the back of this application.
Part 3 – Evidence if you have adults living with you
We must see ORIGINAL proof of their income. This can include wage slips – 5 weekly or 2 paid monthly or a
letter detailing any benefits they might receive.
Part 4 & 5 – You must prove you live at the address and have a rental liability
Provide ORIGINAL evidence to prove you live at your address and have a rental liability. This could be a tenancy
agreement, rent book, rent receipts, or letter from your landlord. Your proof must show the name &
address of your landlord, tenancy start date, amount of rent, and details of what is included with your rent. A
gas, electric, phone bill, or bank statements, sent to your address, will prove your occupancy.
Part 6 – Self Employed Proof
We must see ORIGINAL evidence showing confirmation from HM Revenues & Customs that you have registered
for National Insurance Contributions & Tax. Your last Income Tax assessment & latest certified accounts.
Six months bank statements. Provide evidence of any loan or start up allowance you get.
Part 7 & 8 – Earnings from Employment
We must see ORIGINAL evidence showing what you & your partner earn. Provide 5 weekly or 2 monthly wage
slips. Your proof must show: the name & address of your employer, the hours you work, your gross income in
the year to date, your gross income for the pay period, the amount of Tax deducted, the National Insurance
contributions deducted, method of payment for your wages. If you do not have wage slips show us your
employment contract or letter from your employer.
Part 9, 10 & 11 – Other Income Evidence
You must prove all your income. We will accept the following: ORIGINAL letters from the DWP, Pension
Service or Inland Revenue saying how much you get. ORIGINAL bank statements showing the credits going
into your account. ORIGINAL letters from old employers with details of your pension or award.
Part 12 – Evidence of Savings & Investments
We must see ORIGINAL evidence of all your savings & investments. We need to see your last 2 months bank
statements – even if you do not use the account. Building Society passbooks, share certification, Tax Return
slips. Details of any land or property you own.
20

Advice & information
Take the time to check you’ve answered all the questions and check page 20 to make sure
you have all the evidence we need to assess your claim.
Now choose one of the following options:
Phone 020 7361 3025 and we will register your claim and go through the form with you. We
can call you back so you don’t have to worry about the bill.
You can make an appointment to see someone from the New Claims Team or just visit the
Benefits Section, at The Town Hall, Hornton Street, W8 7NX. Opening times are
8.30 – 5.00 Monday – Friday.
If you have a special need eg elderly or disabled then you can request someone visits you –
call 020 7361 3025.
If you think that you have answered all the questions in full and have all the evidence we
need you could post the form to: The Benefits Section, The Town Hall, Hornton Street,
W8 7NX. We advise that valuable documents are sent by recorded delivery.
When will I know if I get Benefit
If you visit the New Claim Team, complete the form correctly and provide all the proof
needed then your claim could be assessed within 3 days. Contact us if you don’t hear
anything within 14 days.
Rent Restrictions
Private rents in this borough can be very expensive. You do not want to move into a property
to find your rent is restricted because it’s too high or the property is considered too large for
your needs. There are rules that limit the size and rent depending on your age, who lives
with you and the property’s location. Always check with us before you sign a new tenancy.
To discuss your situation and find out what the limit is for privately rented accommodation,
phone 020 7361 3025, or go to our website www.rbkc.gov.uk
Changes in your circumstances
You must tell the Benefits Section of any changes in your circumstances. Even if you have
told the DWP or another Council Department you must also tell the Benefits Section. Failure
to tell the Benefits Section could result in an overpayment that we would recover from you.
Some examples of what you need to report include: changes to your income, changes of
address, rent changes, if anyone leaves or joins your household.
If you are in any doubt tell us anyway.
Contact us if you have any questions:
By Telephone: New Claim Line – 020 7361 3025
By Post or In person: Benefits Section, The Town Hall,
Hornton Street, W8 7NX Reception is open 8:30 – 5.00 Mon – Fri
E-mail: benefits@rbkc.gov.uk
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Monitoring Form
The Council is commited to ensuring the services it provides are fair and accessible to everyone.
Without monitoring we do not know if the policy is working.
In order that we can review our services we would ask that you complete our monitoring form.
We will take full account of the Data Protection Act when we store and analyse the data.
White
How would you best describe your race or ethnic group
1. British
2. Irish
3. Other European
4. Any other White background
Black or Black British
5. Caribbean
6. African
7. Somalian
8. Any other Black background
Asian or Asian British
9. African Indian
10. Indian
11. Pakistani
12. Bangladeshi
Mixed
13. Any other Asian background
14. White and Black Caribbean
15. White and Black African
16. White and Asian
17. Any other Mixed background
Any other group
18. Moroccan Arab
19. Other Arab
20. Chinese
21. Filipino
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22. Any other ethnic background

✂
The Benefits Section
Certificate of Childcare Expenses
People who have to pay for childcare for a child under 15 may be able to get
a higher amount of Housing Benefit or Council Tax Benefit. To qualify for this
extra help, the care must be provided by:
• a registered childminder
• a childminder approved for Tax Credit purposes
• an organisation providing day care, for example a day nursery or playscheme
• a school or local council providing care on school premises, outside of school
hours for children aged 8 to 15; or
• by a childcare scheme in a school or on Crowm Property, exempt from registration.
• a child carer who provides care in the child’s own home (contact us for more details).
Note to any of the above named childminders or organisations
Please complete this form and help our claimant to get full entitlement to benefit.
WARNING: It is an offence to knowingly make or endorse a false statement in support of a
claim for benefit.
Please provide the following information:
Name and address of parent or guardian.
Name:
Address:
Details of children for whom care is provided:
Name of child
Charge for care provided
------------------------------------------------------- £ ------------------------------ per week/month
------------------------------------------------------- £ ------------------------------ per week/month
------------------------------------------------------- £ ------------------------------ per week/month
How often is this care provided For example, 5 days a week, every week of the year, only
during school holidays.
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For Registered Childminders
We need to know your name and address, registration number and the name of the Local Authority with which
you are registered.
Name:
Address:
Phone No:
Which Local Authority are you registered with
What is your OFSTED registration No:
I confirm the information above is corect.
Signature:
Date:
/ /
Other Organisations - What category does your organisation fall in
an organisation providing “day care” for young children under section 71 of the children Act (1989)
a school or local council providing care on school premises, outside of school hours, for children aged
8, 9, or 10.
a childcare scheme on Crown Property, exempt from Registration.
Name and address of organisation
Name:
Address:
Phone No:
Which Local Authority is your scheme registered with
What is your OFSTED registration No:
Address where the “care” is provided:
Address:
I confirm that this organisation provides and charges care as stated above.
Signature:
Date:
/ /
Position of signatory:
Office Stamp
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Please return to: The Benefits Section, The Town Hall, Hornton Street, W8 7NX
If you have any queries, phone 020 7361 3025.