Result

Declaration
Even if someone else has filled in this form for you, please read this
declaration carefully before confirming your acceptance and selecting to
'Submit' your claim.
I declare that the information I have given on this form is correct and complete.
I understand that if I give information that is incorrect or incomplete, you may
take action against me. This may include court action.
I am aware that I must let you know in writing about any change in my
circumstances which might affect my claim. (You may lose benefit if you do not
tell us within one month of that change)
Privacy Notice
We will treat all information provided in confidence and in accordance with our
Privacy Notice. For more information about our Privacy Notice please go to
https://www.derby.gov.uk/privacy-notice/ .
I accept the above terms and conditions. *