NFDC HOUSING/COUNCIL TAX Claim form CL1

Form CL1 - Claim for
Housing Benefit and
Council Tax Reduction
1 About your claim
Your name
Your daytime contact phone number
Property ref:
Claim number:
Issue date
and source:
Please return form by:
If you need help to fill in this form call 01590 646121,
e-mail: benefits@nfdc.gov.uk or visit our website
www.nfdc.gov.uk
Return the filled in form to:
Tax and Benefits Service
Town Hall
Lymington
HANTS
SO41 9ZG.
Do not delay or you
may lose benefit.
Please read the guide that came
with this form, and use a black
ballpoint pen.
Your e-mail address
Do you have a partner living with you?
If “Yes” what date did they move in?
Yes
No
/ /
What is the address for which you are
claiming benefit (including room number if
you have one)?
What date did you move in?
(If you have not yet moved in, please explain)
What was your previous address?
At your previous address were you
(please tick a box and explain, if necessary.)
a tenant an owner/occupier
neither of these
(please explain ,e.g. living with parents)
What are you claiming help with?
Please tick the relevant boxes
Who owns your home?
(please give the names of the legal owners)
………………………………………………………………………………………………………………………………………………………………….
Council Tax bill
Council Rent
Rent (through a Housing Association)
You also need to fill in form CL2
Rent (through a private landlord)
You also need to fill in form CL2
If this is your first claim for benefit with the
Council, you need to provide evidence of
two forms of identity (ID) for yourself (and
for your partner, if you have one)
Please write here what 2 forms of ID you are providing.
The guide tells you what is acceptable
Office use:
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Surname
2 About you and your partner
'Partner' means your husband or wife or a person you
are living with as if you were married or a civil partner
or a person you live with as if you were civil partners.
You
If you do not have a partner,
write 'none' in this box.
Your partner
First and middle names
Date of birth
National insurance number
We need to see evidence of this
Are you or your partner retired? Yes No Yes No
Yes No Yes No
Are you or your partner working full time (16
hours or more a week)? You need to fill in
form CL4.
Are you or your partner working part-time (less
than 16 hours a week)? You need to fill in form
CL4.
Are you or your partner due any redundancy pay
or pay in lieu of notice?
Do you or your partner have a vehicle provided
by a Motability scheme?
Does anyone receive Carer’s Allowance for
looking after you or your partner?
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Are you or your partner in legal custody? Yes No Yes No
Are you or your partner registered blind? Yes No Yes No
Are you or your partner in an NHS hospital? Yes No Yes No
If ‘Yes, when did you go in? / / / /
Are you a student?
Yes No Yes No
Where are you studying?
Where:
Start date of course:
Where:
Start date of course:
Are you receiving a student grant, bursary or
loans? We will need to see your student
grant/bursary award notification and details of
any student loans.
Is your course full time or part time?
End date of course:
End date of course:
Yes No Yes No
full time? part time? full time? part time?
What is your nationality?
Have you come to live in the UK within the last
five years?
If “Yes” we will ask for further information.
Yes No Yes No
Office use:
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3 About dependent children
We need to know about any children in your household who are aged under 16 or aged
between 16 and 20 and in education. Are there any children in your household?
Yes No If ‘Yes’ please give details below.
Last name
Other names
Date of birth
Relationship to you or your partner
Who gets the Child Benefit for them?
1st child 2nd child 3rd child 4th child
Are they In full-time education? Yes No Yes No Yes No Yes No
Please give the date, or if not known
the expected date, of when they will
end their education?
Is the child registered blind or getting
Disability Living Allowance? Yes No Yes No Yes No Yes No
Amount of savings or investments
they have.
£ £ £ £
4 About other people who live with you
Does anyone else live with you and your partner? (This includes anyone studying away at university during term
time) Yes No If ‘Yes’ please give details below. If ‘No,’ go to the next page.
Title and last name
Other names
Date of birth
National insurance number
Relationship to you or your partner
Date they moved in to this address
1st person 2nd person 3rd person
Are they a joint owner or tenant?
Yes No Yes No Yes No
Do they pay rent or money for board to
you or your partner? Yes No Yes No Yes No
Do they work more than 16 hours a
week? Yes No Yes No Yes No
If ‘Yes’, how much do they earn, before
tax? (We need to see evidence)
£ every £ every £ every
Amount of any other money they have
coming in? Please say what.
(We need to see evidence)
Do they get Income Support,
Employment and Support Allowance,
Jobseekers Allowance or Pension
Credit?
Are they a full-time student, student
nurse, care worker or apprentice?
If “Yes” tell us which.
If they are in hospital, when did they go
in?
£ £ £
Yes No Yes No Yes No
Yes No Yes No Yes No
/ / / / / /
If they are in prison, when do they
expect to be released? / / / / / /
Are they a careworker provided by a
charity or voluntary organisation? Yes No Yes No Yes No
If any of these people are living
together as a couple, please tell us.
Office use:
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5 About money, savings, investments and property
You must supply statements
for the past 2 months
Details You Your partner
Do you or
your partner
have any
Bank or
building
society
accounts
Account name and number Balance Account name and number Balance
Yes
No
You must send us original evidence if
you have any of these
Do you or
your partner
have a Post
Office
account
Yes
No
Account number Balance Account number Balance
Do you or
your partner
have any
Stocks and
shares
Yes
No
Name and number of shares Value Number of shares Value
ISA, Bond,
Unit Trust,
Premium
bonds
Yes
No
Name of ISA, bond, unit trust Amount Name of ISA, bond, unit
trust
Amount
Do you or your partner have any other savings or investments, such as a
paypal account, national savings certificates, cash over £250?
Yes
No
You
Your partner
How much
How much
Where is it
invested
Where is it
invested
Do you or your partner own any other property or land (not including
the property you are claiming for?
What is the address?
Yes
No
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Is the property up for sale? Yes No
Is the property being rented out?
If “Yes” please say how much?
Yes
£
No
If “Yes” please confirm:
a) the date it was placed on the market / /
b) the current market value? £
c) outstanding mortgage? £
Claim no.

6 About Pensions
Do you get any pensions? Yes
No
You must send us original evidence if
you are getting any of these pensions
If 'Yes', please give the details below and say when your benefit started, how much you or your partner
are entitled to (which may be different from what you actually get) and how often.
You
Your partner
State Retirement Pension £ every £ every
Pension (Guarantee) Credit £ every £ every
Pension (Savings) Credit £ every £ every
Widow's Pension £ every £ every
War Disablement Pension £ every £ every
War Widow's Pension £ every £ every
Industrial Injuries Pension £ every £ every
Pension from a former employer or
pension scheme (after deducting only
tax). We will need to see evidence
£ every £ every
Who pays this pension?
When did your pension last go up or when
is it due to go up?
Do you have any other
personal pensions?
/ / / /
YES NO YES NO
If ‘Yes’, how much? £ every
£ every
£ every
£ every
Who pays them?
When did they last go up, or when are
they due to go up?
Do you have any pensions from a former
employer or pension scheme which you
have deferred? (If “Yes” please provide
details)
7 About State Benefits
Do you or your partner get any of these benefits? Yes
/ / / /
YES NO YES NO
If 'Yes', please give details below and say when your benefit started, how much you or your partner are
entitled to (which may be different from what you actually get) and how often.
Disability Living Allowance or
Personal Independence Payments
No
Date started You Your partner
/ / £ every £ every
Incapacity Benefit / / £ every £ every
Industrial Injuries Benefit / / £ every £ every
Carer’s Allowance / / £ every £ every
Severe Disablement Allowance / / £ every £ every
Attendance Allowance / / £ every £ every
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Office use:
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8 About other State Benefits & Tax Credits
Do you or your partner get any of these benefits? Yes
If 'Yes', please give the details below and say when your benefit started, how much you or your
partner are entitled to (which may be different from what you actually get) and how often.
No
Send us original evidence if you are
getting any of these benefits
Child Benefit
Child Tax Credit
Working Tax Credit
Guardian's Allowance
Maternity Allowance
Widowed Parent’s
Allowance
Bereavement Allowance
Any other benefit
(Please say which)
Date
started
You
Your partner
/ / £ every £ every
/ / £ every £ every
/ / £ every £ every
/ / £ every £ every
/ / £ every £ every
/ / £ every £ every
/ / £ every £ every
/ / £ every £ every
If you are getting any of these benefits you do not have to send us evidence
Employment and
Support Allowance
Income Support
Jobseeker’s Allowance
(Income Based)
Jobseeker’s Allowance
(Contributions Based)
/ / £ every £ every
/ / £ every £ every
/ / £ every £ every
/ / £ every £ every
9 State Benefits & Tax Credits claimed (waiting to
hear about)
Have you or your partner claimed any State Benefits or Tax Credits that you are waiting to
hear about? Yes No
If ‘Yes’, please say what you have claimed
and when you made your claim. Don’t
forget to tell us when you hear about your
claim – if you do not do this you may lose
benefit or have to pay back benefit you are
not entitled to.
Date claim made: / /
Office use:
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10 About income
Do you or your partner have any of the income shown below? Yes No
If 'Yes', please give details below, saying how much you or your partner get and how
often. If ‘No’, please go through the checklist below.
Are you or your partner in employment?
If “Yes”, you must fill in form CL4 giving details
and also provide evidence of earnings.
You must send us original evidence of any of this income
You
Your partner
Yes No Yes No
Maintenance you receive
(other than for a child)
£ every £ every
Maintenance for a child £ every £ every
Money from renting out property
Please write down the address.
(We may write to you for more information.)
£ every £ every
Money you get from boarders or lodgers £ every £ every
Charitable or voluntary payments you get £ every £ every
Any other money you get that you have not
put down already (please say what it is) £ every £ every
Before you go any further go through this checklist:
Have you fully answered all the sections of the form(s), including if you
have a partner and all the boxes on page 4? Yes (if not, please do so, or we
will not be able to deal with your claim).
Have you enclosed evidence of your (and your partners):
• ID and National Insurance Number Yes No
• Statements of all money, savings and investments Yes No N/A
• All State and Occupational/Private Pensions Yes No N/A
• All State Benefits Yes No N/A
• Any other income Yes No N/A
If you (or your partner) are working:
• Have you filled in form CL4? Yes No
• Have you enclosed recent payslips? Yes No (If the employment has only recently
started a letter from the employer will do)
• Have you enclosed evidence of Tax Credits? Yes No N/A
If you are a tenant of a private landlord or of a housing association:
• Have you filled in form CL2? Yes No
• Have you supplied evidence of your rent, e.g. a tenancy agreement? Yes No
Benefit is normally awarded from the Monday after we receive your claim. Do not
delay sending back this form, even if you cannot provide all of the evidence we
need. Make sure you tell us why you cannot, and when you expect to be able to
provide it. Without all the information we cannot pay benefit!
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11 Anything else you need to tell us
You can use the space below to give us any extra information about your claim or if
you know of any future changes in your circumstances that may affect your benefit.
This could include changes to your earnings, Tax Credits, pensions, household or
bank accounts.
12 About when your benefit starts
We usually award benefit from the Monday after we receive your claim. Sometimes we can
award benefit from an earlier date if you have good cause for not making you claim earlier. If
you want us to consider awarding you benefit from an earlier date, use a separate sheet of
paper to tell us when you want your benefit to start from and why you did not claim earlier.
YOUR DECLARATION – PLEASE READ CAREFULLY
Even if someone else has filled in this form for you, you must sign this declaration
if you can. If you have a partner, they must sign this declaration as well.
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 the information I have provided to process my claim for housing benefit or council tax
reduction, or both. You may share and check information with other offices within the council, rent
offices and other councils.
• New Forest District Council is under a duty to protect the public funds it administers, and
to this end may share information in respect of my claim for Housing Benefit or Council
Tax Reduction internally, and with other council’s and government agencies including
other bodies responsible for auditing or administering public funds, for the prevention
and detection of fraud.
• I know I must inform the Tax and Benefits office of any changes in my circumstances which
might affect my claim without delay. I understand that The Department for Work and
Pensions will not do this on my behalf, even if I notify them of the change.
• I declare that the information I have given on this form is correct and complete.
Signature of person claiming ……………………………………. Date …………………………
Signature of Partner ……………………………………………… Date ……………………………
Forms filled in by someone other than the person who is claiming
Please tell us why you are filling in this form for the person claiming.
Name of the person who filled in the form ……………………………………….
Signature of the person ……………………………………………………………
Relationship to the person claiming ……………………………………………..
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Please return this form as soon as possible, even if you cannot provide
all of the evidence we need. Make sure you tell us why you cannot
provide the evidence, and when you expect to be able to provide it.
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