Forms home Council Tax Hardship Payment 1Before you apply2Personal details3Household4Circumstances 15Circumstances 26Financial statement 17Financial statement 28Financial statement 39Declaration Important - you must be receiving Council Tax Reduction to be considered for a Hardship Payment Hardship Payments are extra payments towards Council Tax. They may be awarded to people receiving Council Tax Reduction. HPs are not intended to be long term. They are awarded on a short term basis while you take action to improve your circumstances. If you are awarded a HP it will be credited to your Council Tax Account. If you need extra help to pay your Council Tax you should complete this form. Please give us as much information as possible to help us understand why your circumstances are exceptional. We may contact you by telephone or email to gather further information. A decision regarding your HP request will be delayed if you do not provide the relevant information to support your application. CTR reference number Enter your 8 digit Housing Benefit/Council Tax Reduction number if known. If not, leave this field blank.Name* Date of birth* DD slash MM slash YYYY National Insurance Number* Address* Street Address Address Line 2 City Post code Telephone numberEmail Address* Do you receive Council Tax Reduction? Yes No You should not continue with completing this form. To be considered for a Hardship Payment you must be receiving Council Tax Reduction. Please list all the members of your householdNameDate of birthRelationship to you If there are other adults in your household, apart from your partner, you are required to provide evidence of their income – e.g. benefits, payslips, student finance Drop files here or Select files Max. file size: 10 MB. Do any of the following circumstances apply to you?Does anyone in your household require an overnight carer who normally lives elsewhere?* Yes No Please provide detailsAre you or your partner a registered foster carer?* Yes No Please provide detailsDo you have a child that is unable to share a bedroom with another child due to disability?* Yes No Please provide detailsAre you unable to share a bedroom with your partner due to disability?* Yes No Please provide detailsIs a bedroom in your property used for a member of your household currently serving in the armed forces but is away on operations?* Yes No Please provide detailsHave you suffered a bereavement of a household member in the last year?* Yes No Please provide details Are you or a member of the household terminally ill with a life expectancy of 6 months or less?* Yes No Please provide detailsAre you or a member of your household undergoing treatment for cancer or other life threatening illnesses?* Yes No Please provide detailsHave you or your partner recently lost your job and not received Universal Credit within the last year?* Yes No Please provide detailsHave you or your partner started full time work (36 hours) after a period of unemployment of more than a year?* Yes No Please provide detailsHas an immediate member of your household died?* Yes No Please provide detailsPlease provide detailsHave you been placed in temporary accommodation in the borough for the first time? Yes No Please provide detailsDo you have a child under 3 months old?* Yes No Please provide detailsHave you recently adopted a child?* Yes No Please provide detailsAre you subject to the Benefit Cap for the first time?* Yes No Please provide detailsPlease provide detailsAre you a victim of domestic violence?* Yes No Please provide details Is there any further information you would like to give to support your application? Please provide details and explain why you believe your circumstances are exceptional.Hardship Payments are intended to be for short term periods only. Please tell us what your future plans are to improve your situation when any award expires. Financial StatementIncome - please list all of your income including benefits below for you and/or your partner.TypeHow much?How often? If you are employed, please provide your two most recent salary slips. If you are self-employed, please provide your most recent profit and loss records. If you receive Universal Credit (UC), please provide evidence of your most recent monthly payment – this can be found on your journal and should include the breakdown of all elements that make up the payment, including deductions. Drop files here or Select files Max. file size: 10 MB. Contributions from non-dependant household membersNameHow much?How often? Priority Bills - please include regular payments only - there is a separate section for arrears paymentsMortgage and/or loans secured on your homeHow much?How often? Council TaxHow much?How often? GasHow much?How often? Please provide your latest bill.Max. file size: 10 MB.ElectricityHow much?How often? Please provide your latest bill.Max. file size: 10 MB.Payments ordered by a courtHow much?How often? Please specifyPlease provide evidence Drop files here or Select files Max. file size: 10 MB. Child Support PaymentsHow much?How often? Please provide evidence Drop files here or Select files Max. file size: 10 MB. TV LicenceHow much?How often? Disability Related Costs – if you or any member of your household receives Disability Living Allowance or Personal Independence Payments, please list any specific expenditure that you use these benefits for.TypeHow much?How often? Household costsHousehold Shopping including food, toiletries and laundry and cleaning products.How much?How often? School MealsHow much?How often? Water RatesHow much?How often? Clothing For you, your partner and dependants onlyClothesHow much?How often? ShoesHow much?How often? ChildrenNappies, formula milk & baby products.How much?How often? ChildcareHow much?How often? School UniformHow much?How often? Other, please specify how much and how oftenTravelPublic TransportHow much?How often? Car TaxHow much?How often? Car InsuranceHow much?How often? Car servicing, MOT and repairsHow much?How often? Other travel expenses, please specify how much and how often InsuranceLife InsuranceHow much?How often? Buildings insuranceHow much?How often? Contents insuranceHow much?How often? Other insurance, please specify how much and how oftenCommunicationsLandlineHow much?How often? Mobile – for you, your partner and dependants onlyHow much?How often? InternetHow much?How often? Combined package, please specify how much and how oftenLeisureSatellite/Cable TV – if not included aboveHow much?How often? CigarettesHow much?How often? AlcoholHow much?How often? Other, please specify how much and how oftenPeople and petsPayments to student childrenHow much?How often? Regular Charitable donationsHow much?How often? PetsHow much?How often? Other, please specify how much and how oftenDebtsLoansName of companyRepaymentHow often?Outstanding balance Credit cardsName of companyRepaymentHow often?Outstanding balance Utility arrears e.g gas, electricityName of companyRepaymentHow often?Outstanding balance Overpayments of State Benefits, Tax Credits or Housing BenefitName of companyRepaymentHow often?Outstanding balance Store cardsName of companyRepaymentHow often?Outstanding balance Other, please specifyPlease include name of company, repayment, how often and outstanding balance Declaration - please read this carefully before you sign If I give information that is incorrect or incomplete, you may take action against me You will use the information I have provided to assess my application for a Hardship Payment I authorise you to make any necessary enquiries to check the information I have provided You may use the information I have provided in connection with this and any claim for Social Security benefits that I have made or may make You may give information to other Government organisations if the law allows this I must let you know about any changes in my circumstances that may affect my application I declare the information I have given on this form is correct and complete Typing your full name here is assumed as your electronic signature.* Did you complete this form yourself? Yes No This section must be completed if this form has been completed for you by someone else.Name of the person completing the form Relationship to the applicant or officer details Please tell us why you have completed this form for the applicantEmail address Phone numberWork Redbridge Work Redbridge can help and support residents looking for work, training, volunteering or self-employment opportunities. Find out more by visiting our Work Redbridge webpageIf you are working age and unemployed we will pass your details to Work Redbridge to contact you with further information. If you wish to opt out of this, please indicate below* Yes No
