Emergency Hardship Fund

Council Tax Reduction - Exceptional Hardship Fund
Section 1 - Personal Details
1. Full Name:*
2. Claim reference number:
3. Email:*
4. Telephone Number:*
5. Date of Birth*
6. National Insurance Number*
Address lookup
1. Postcode*
  
  Address
Please provide your last 3 months statements for all bank/building society accounts held as evidence of your outgoings.
Section 2 - Weekly Outgoings
1. Food*
2. Household Items*
3. Clothing*
4. Mortgage*
5. Mortgage Arrears*
6. Council Tax*
7. Council Tax Arrears*
8. Electricity*
9. Gas*
10. Coal/Heating Oil*
11. Water Rates*
12. Telephone*
13. TV/DVD/Video Rental*
14. Insurances*
15. Car Expenses*
16. Petrol*
17. Bus Fares*
18. Childcare Costs*
19. Travel to Work*
20. Loan Payments*
21. Credit Card Payments*
22. Other (Please Give Details)
  1. Any other Outgoings
  2. Amount
23. Group2
  1. Any other Outgoings
  2. Amount
24. Group2
  1. Any other Outgoings
  2. Amount
25. Group2
  1. Any other Outgoings
  2. Amount
26. Group2
  1. Any other Outgoings
  2. Amount
27. Weekly Outgoings Calculator
  1. Weekly Total*
Section 3 - Weekly Income
1. IS/JSA/ESA Other Benefits*
2. Universal Credit*
3. Housing Element of UC*
4. Wages for you*
5. Wages for your Partner*
6. Child Benefit*
7. Child Tax Credit*
8. Working Tax Credit*
9. Pension Credit*
10. DLA (Mobility)*
11. DLA (Care)*
12. Attendance Allowance*
13. Maintenance Received*
14. Other (Please Give Details)
  1. Any other Income
  2. Amount
15. GROUP7
  1. Any other Income
  2. Amount
16. GROUP8
  1. Any other Income
  2. Amount
17. GROUP9
  1. Any other Income
  2. Amount
18. GROUP10
  1. Any other Income
  2. Amount
19. GROUP11
  1. Any other Income
  2. Amount
20. GROUP12
  1. Any other Income
  2. Amount
21. GROUP13
  1. Any other Income
  2. Amount
22. GROUP14
  1. Any other Income
  2. Amount
23. Weekly Income Calculator
  1. Weekly Total*
1. Why do you need this extra help?
1. Tell us about your weekly income within the household and the way you spend it.
  
  Can you get help towards the shortfall in your housing costs from other members of your family?
  
  What sort of contribution are you prepared to make, to meet the shortfall?
  
  Tell us about any debts you have and how much they are, including any rent or Council Tax Arrears (provide evidence of any rent arrears).
2. Extra Help*
3. Based on your budget, what is the most you can afford to pay towards your rent?
  
  £ Weekly amount a week
  
  Based on your budget, what is the most you can afford to pay towards your Council Tax bill?
  
  £ Monthly amount a month
2. What are your family circumstances?
1. Tell about any disabilities, health problems, special needs etc. for you or your family. Has your property been adapted to assist with any disability? If you receive DLA or PIP how do you spend this money? (continue on a separate sheet of paper if necessary).
2. Family circumstances*
3. If you own your property and are applying for help with your Council Tax only go straight to Question 6. Declaration
3. What have you done to help yourself? Have you received any debt advice? What was the outcome of any advice?
1. Tell us if you have tried to re-negotiate the rent with your landlord, you have looked for cheaper accommodation or signed up with Devon Home Choice. Is there a particular reason why you cannot move, were you aware that your rent would not be met in full when you accepted the tenancy and if so, how you had planned to meet it. Have you sought any debt advise and if so where from?
2. Help yourself*
4. Is there anything else that you can tell us about your need for an exceptional hardship payment?
1. Anything else
5. Declaration
1. Please check that you have completed the form accurately and then read and sign the following declaration.
  
  I understand all of 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 check my claims for Discretionary Housing Payments, Council Tax Reduction / Housing Benefit. You may check some of the information with other council records and with other councils.
  
  I know that I must let the Benefits Team know about any changes in my circumstances that may affect my claim.
  
  I declare that the information I have given on this form is correct and complete.
  
  I give permission to pass on my details to third party agencies for assistance with debt and money advice.
  
  Please tick to confirm if you agree with the above statement: Check Declaration2
4. If someone else has helped you complete this form, please give their details here:
5. Full Name
6. Relationship to you

Council Tax Reduction - Exceptional Hardship Fund