Housing Benefit and Council Tax Support Review form

Step 1 of 4

Personal and contact details

Your Full Name(Required)

First name Middle name Last name

Your Reference Number(Required)

This is your benefit reference which starts with 80. This can be found in the top right corner of the Housing Benefit review letter sent out to you

Your National Insurance Number(Required)

Your date of birth(Required)

Address(Required)

House/Flat Number Street Name City/Town Post Code

If you would like us to contact you by phone or email about your housing benefit and or council tax support claim please provide your details in the section below:

Phone

Your Declaration

Even if someone else has filled this form in for you, you must sign this declaration if you can.

Please read this declaration carefully before you sign it: I understand the following:

I understand that this claim form is made to you, Hyndburn Borough Council.

I confirm that as far as I know, the information I have provided on this form is correct and complete

I understand that if I have given information that is incomplete or incorrect that you may take legal action against me

I agree that you will use the information provided to process my claim for Housing Benefit and you may check some of the information with other sources as the law allows.

I know that I must let you know in writing straight away about any change in my circumstance that could affect my claim.

The council will use your information in line with the Data Protection Act 1998. We have a duty to protect public funds and we may use the information you have given us or share it with other organisations to prevent and detect fraud.

The council will also share your information if we have a legal duty to do so, or where we believe that by doing so we can provide you with a better standard or service.

I understand that the Council sometimes will need information about people other than the person who has applied for Housing Benefit or Council Tax Support to work out what that person is entitled to. You may check some of the information with other sources as allowed by the law.

For example, where a person makes a claim for Housing Benefit, we need information about the income and capital of other people who live in the same household as the person claiming, to work out how much Housing Benefit the person will be paid.

I understand and agree that the information held by you for the purposes of my claim may be shared with the Local Education Authority for the purpose of determining a child’s eligibility for free school meals or any other benefit, and with Lancashire County Council or BT Lancashire for the purpose of determining my entitlement to a Social Fund Loan or other similar benefit.

I know that I must let you know in writing about any change in my circumstances which might affect my claim.

Has this form been completed by someone other than the claimant?(Required)

Yes

Your name if you have completed this form for the claimant:(Required)

First name Middle name Last name

Your relationship to the claimant(Required)

Your signature(Required)

Claimant's Name(Required)

First name Middle name Last name

Claimant's signature(Required)

Date(Required)

The date this form was completed

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