Apply for Discretionary Housing Payments 1 Personal details 2 Your household 3 Income 4 Capital and Savings 5 Outgoings 6 Review Your Answers 7 Declaration 8 Submit Progress Personal details Name Date of birth National insurance number Housing Benefit Claim number Postcode Find AddressEnter your address manually Email Telephone Mobile Please select your preferred method of contact ---Please select--- Email Phone Call Letter Other Other contact method Your household Does your Housing Benefit or housing element of Universal Credit meet your full rent? Yes No Please note: Discretionary Housing Payments can only help people who need extra help with their rent when their Housing Benefit or housing cost element of Universal Credit does not meet the full value of their rent. Do you have any rent arrears? Yes No How much and what period do they cover? What action has your Landlord taken to recover your rent? ---Please select--- Court Action Notice seeking Possession Payment Plan Other Other actions Please upload rent arrears evidence Have you (or your partner if you have one) applied for a Discretionary Housing Payment before? Yes No Please explain what has changed since your last application and what steps you have taken to find cheaper accommodation, increase your income, or reduce your outgoings? If you have been unable to take any of these steps, or if you think this does not apply to you, please explain why Please tell us why you need extra help with your rent Please tell us why you need extra help with your rent Are you taking any steps to find cheaper accommodation, increase your income, or reduce your outgoings? (If you are unable to take any of these steps, or if you think this does not apply to you, please explain why) Do you have a partner? Yes No Please provide some information about your partner. Name Date of birth National insurance number By children we mean a child under the age of 20 who you are getting Child Benefit for. Click + to add childs date of birth. Do any children live with you? Yes No Enter name of child + Do any children living with you attend a nearby school or childcare? Yes No Do you have any children who do not live with you? Yes No Please provide details Do any other adults live with you? Yes No Please provide full name, relationship to you and date of birth. Click + to add date of birth and relationshop to you. Enter name of adult + Are you or any member of your household disabled? Yes No Please provide details Has your property been adapted as a result of your / a member of your household's disability? Yes No Please provide details If you have any evidence of this please provide proof Do you or your partner have a non-resident overnight carer or team of carers who provide care on a regular basis? Yes No Do they have their own bedroom? Yes No Name of and address of carer(s) Are you or any member of your family expecting a baby? Yes No Who is expecting baby? Expected due date Does your household include a student who lives away during term time? Yes No Name of student Term time address Name of University / College University / College start date Length of course Does your household include a member of the armed forces who lives with you when home on leave? Yes No Name of person serving Address where serving If you have any evidence of this please provide proof Are you a registered foster carer? Yes No Please provide evidence if you have not already done so Income Tell us about all income you and your partner receive. Please ensure that this is as accurate as possible so that we can make an informed decision on your current circumstances. Please select the period for which you would like to specify your incoming and outgoings. -- Please select -- Monthly Fortnightly Weekly Do you receive Universal Credit? Yes No Are you or your partner claiming Universal Credit? You Partner To consider your application, we need to see proof of the amount and breakdown of your Universal Credit award, and the level of your rent. If possible, please provide this with your application in order to prevent delay. Amount £ Current rent charge £ Please provide evidence of your current rent charge. If you are re-applying for a DHP and your rent has changed since your last application then please provide evidence of your new rent charge to help us assess your application. Date tenancy started Number of bedrooms Name and address of Landlord Please provide your bank details. Name on Account Please provide details Sort code Account number Please provide a copy of your most recent UC Award Letter or screen shots from your online journal to help us process your application. Your details Job Seekers Allowance £ Income Support £ Employment Support Allowance £ Child Benefit £ Child Tax Credit £ Working Tax Credit £ Pension Credit £ State Retirement Pension £ Occupational / Works Pension £ Personal Independence Payment £ Disability Living / Attendance Allowance £ Carers Allowance £ Earnings - Take Home Pay £ Self Employed Earnings £ Any other state benefit £ Your partner's details Job Seekers Allowance £ Income Support £ Employment Support Allowance £ Child Benefit £ Child Tax Credit £ Working Tax Credit £ Pension Credit £ State Retirement Pension £ Occupational / Works Pension £ Personal Independence Payment £ Disability Living / Attendance Allowance £ Carers Allowance £ Earnings - Take Home Pay £ Self Employed Earnings £ Any other state benefit £ Any other type of income (including earnings from additional jobs) + Capital and Savings Please tell us about any capital, savings or investments you have. If you have a partner you will also need to include any capital, savings or investments they have. Your partner's capital savings Bank / Building Society Accounts £ Saving Certificate / Bonds £ Stocks / Shares £ Property / Land £ Property / Land £ Partner capital savings Bank / Building Society Accounts £ Saving Certificate / Bonds £ Stocks / Shares £ Property / Land £ Property / Land £ Outgoings Please tell us about your (and your partners if you have one) regular household outgoings Please enter your monthly outgoings Rent £ Gas £ Electricity £ Water £ Council Tax £ Food £ Toiletries £ TV Licence £ Travel costs / bus fares £ Clothing £ Telephone - landline £ Mobile Phone £ Broadband £ Satellite or cable television £ Home Insurance £ Life Assurance £ Pet Insurance £ Car Insurance / Road Tax £ Petrol / Diesel £ Childcare or maintenance £ Savings £ Other expenditure + Debts - Please list any outstanding debts – examples of debts include gas, electricity, water rates, loans, DWP loan repayments, credit union payments, credit/store cards, catalogue payments, hire purchase agreements, Court Orders’ Enter name of lender / company Have you made any enquiries about reducing the Amount(s) you are paying? Yes No Tell us what enquiries have been made and what was the outcome. Review Your Answers Declaration Are you the person making the claim, or have you answered the questions on behalf of the person making this claim? Yes No What is your name? What is your relationship to the person making the claim? ---Please select--- Appointee Support Worker Customer Service Advisor Welfare Rights Officer Landlord Relative Friend Other What is your relationship to the person making the claim? ---Please select--- Appointee Support Worker Customer Service Advisor Welfare Rights Officer Landlord Relative Friend Other Other contact method Has the person making the claim given you permission to answer the questions on their behalf? Yes No Please provide Power of Attorney or DWP Appointee documents Declaration I understand the following: You will use the information I have given you to process my application for a Discretionary Housing Payment. You may check the information with other sources within the council, and other councils or government departments. You may use any information I have given you in connection with this and any other claim for social security benefits that I have made or may make. You may give some information to other government organisations or local authority services, if the law allows this. I understand that if I give incorrect or incomplete information or I fail to report any change of circumstances which might affect my benefit, you may take action against me and that this could involve prosecution. I declare that the information I have given on this form is correct and complete. I will tell you immediately if any circumstances change Agree Terms It may help to speed up your claim if we are able to contact your landlord directly to verify any additional details which may be required. This could include confirming the amount of your rent, or details of any rent arrears, for example. Do you give us permission to contact your Landlord if we need further information in order to consider your Discretionary Housing Payment application? Yes No Additional Assistance Please tick this box if you want us to tell you about your possible entitlement to other benefits, discounts, grants and council services. Are you struggling with debts and need help to resolve them? Tick the box if you would like us to refer you to the Citizens Advice Bureau for debt advice. We can refer you to our partner agency, Liverpool Citizens Advice Partnership (LCAP) who can provide you with support with managing your money and paying your bills. Tick the box if you would like us to refer you to LCAP. If you are worried about losing your home or thinking about moving and want advice, the Council's Housing Options Team may be able to help. If you would like us to send details to the Housing Options Team please tick the box. Submit