Forms home Discretionary Housing Payment and/or Hardship Payment 1 Before you apply2 Personal details3 Household4 Circumstances 15 Circumstances 26 Financial statement 17 Financial statement 28 Financial statement 39 Declaration Discretionary Housing Payments are extra payments to help towards rent. Hardship Payments are extra payments towards Council Tax. DHPs cannot be used to cover costs which are not eligible for housing benefit, for instance: ineligible service charges increases in rent due to outstanding arrears certain sanctions and reductions in benefit a housing benefit or universal credit overpayment The funds for Discretionary Housing Payments are allocated to Local Authorities by the Department for Work and Pensions. The funds for Hardship Payments come from within the Local Authorities own budget. DHPs and HPs may be paid to people receiving Housing Benefit, the housing element of Universal Credit and/or Council Tax Reduction. DHPs cannot be used to cover certain elements of your rent such as meals, heat, lighting, hot water or water charges. DHPs and 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 DHP it will be paid with your Housing Benefit. If you are awarded a HP it will be credited to your Council Tax Account. If you need extra help to pay your rent or 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 or ask you to come into the office to gather further information. A decision regarding your DHP request will be delayed if you do not provide the relevant information to support your application. HB reference numberEnter your 8 digit Housing Benefit/Council Tax Reduction number if known. If not, leave this field blank.Name(Required)Date of birth(Required) Date Format: DD slash MM slash YYYY National Insurance Number(Required)Address(Required) Street Address Address Line 2 City Post code Telephone numberEmail Address(Required) What do you need help with: Weekly rent Rent arrears Council Tax 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 Are you affected by a restriction to the number of bedrooms you are entitled to?(Required)YesNoDo any of the following circumstances apply to you?Does anyone in your household require an overnight carer who normally lives elsewhere?(Required)YesNoPlease provide detailsAre you or your partner a registered foster carer?(Required)YesNoPlease provide detailsDo you have a child that is unable to share a bedroom with another child due to disability?(Required)YesNoPlease provide detailsAre you unable to share a bedroom with your partner due to disability?(Required)YesNoPlease 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?(Required)YesNoPlease provide detailsHave you suffered a bereavement of a household member in the last year?(Required)YesNoPlease provide details Are you or a member of the household terminally ill with a life expectancy of 6 months or less?(Required)YesNoPlease provide detailsAre you or a member of your household undergoing treatment for cancer or other life threatening illnesses?(Required)YesNoPlease provide detailsHave you or your partner recently lost their job and not received Housing Benefit or Universal Credit within the last year?(Required)YesNoPlease provide detailsHave you or your partner started full time work (36 hours) after a period of unemployment of more than a year?(Required)YesNoPlease provide detailsHas an immediate member of your household died?(Required)YesNoPlease provide detailsHave you been placed in temporary accommodation out of the borough for the first time?(Required)YesNoPlease provide detailsHave you been placed in temporary accommodation in the borough for the first time?YesNoPlease provide detailsDo you have a child under 3 months old?(Required)YesNoPlease provide detailsHave you recently adopted a child?(Required)YesNoPlease provide detailsAre you subject to the Benefit Cap for the first time?(Required)YesNoPlease provide detailsAre you subject to a bedroom restriction for the first time due to a change in your household?(Required)YesNoPlease provide detailsAre you a victim of domestic violence?(Required)YesNoPlease provide details Are you making any rent payments to your landlord?(Required)YesNoPlease provide detailsDo you have rent arrears?YesNoYou do not need to provide this information if the Council is your landlord.How much do you owe?Please provide amount and period. DHP awards to help you with your arrears will usually be paid directly to your landlord. Please provide their bank details – account name, account number and sort code.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.Discretionary Payments are intended to be for short term periods only. Please tell us what your future plans are to improve your situation when any discretionary 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 Contributions from non-dependant household membersNameHow much?How often? Priority Bills - please include regular payments only - there is a separate section for arrears paymentsRentHow much?How often? Please provide your most recent rent statement. This should be a month-by-month account of rent due, payments made and arrears outstanding Drop files here or Mortgage and/or loans secured on your homeHow much?How often? Council TaxHow much?How often? Please provide your Council Tax bill if you do not live in Redbridge.GasHow much?How often? Please provide your latest bill.ElectricityHow much?How often? Please provide your latest bill.Payments ordered by a courtHow much?How often? Please specifyPlease provide evidence Drop files here or Child Support PaymentsHow much?How often? Please provide evidence Drop files here or 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 If your application for a Discretionary Housing Payment is successful we may pay this into your bank account. Please provide the following details: Account nameSort codeAccount number 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 Discretionary Housing Payment and/or 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.(Required)Did you complete this form yourself?YesNoThis section must be completed if this form has been completed for you by someone else.Name of the person completing the formRelationship to the applicant or officer detailsPlease 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(Required)YesNo
