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Discretionary Housing Payments Form

To be considered for a Discretionary Housing Payment you must complete Discretionary Housing Payments form and send it to the Benefits Section along with supporting documentary evidence.


When you complete the form you will be asked to say why you should get an additional payment towards your rent and/or Council Tax payments, what your circumstances are, any action you have taken to help yourself and anything else you think may help them make a decision.

You will also need to tell them about all the money you have coming into your household (income) and all the money you pay out each week/month (expenditure) and you may be asked to provide your last three months bank statements.

It’s not a requirement of the scheme that councils ask you to fill in a form but most do and the most common questions you will need to answer are:-

Example information requested for Discretionary Housing Payment Form.

You must answer all questions . You must provide relevant proof (for example, a statement of your rent arrears or evidence of loans). If you delay sending this proof, it will take longer to deal with your application as they will have to write to you for this information. (If you cannot get relevant proof at the time of your claim, please do not delay sending your application as the date of award of a payment from will depend on the date they receive your application. You should tell that you will send proof later, and send the proof to as soon as possible.) Please make sure that you provide full details of any exceptional circumstances, or reasons why you are having difficulties meeting your housing costs.

Your first name:

Your surname:

Your address and postcode:

When did you move to this address

Did you move in during the last 12 months?

Reasons for your claim (Continue on a separate sheet if necessary, making sure your name and address are clearly shown.)

What was your previous address?

Did you claim Housing Benefit or Council Tax Benefit at this address?

If yes, why did you leave?

Do you have any connection with this borough?

If yes, please give details

If no, why did you choose our area rather than another?

Are you renting from a private landlord?

Did your tenancy start after 2

January 1996?

If yes, did you ask for a ‘pre-tenancy determination’ before you moved in?

If no, please explain why

Have you appealed against the Rent Service’s decision for your home?

Have you asked the landlord to reduce the rent?

If yes, what was the outcome?

Have you received a ‘notice seeking possession’?

Have you received a summons for unpaid Council Tax?

Have you tried to find cheaper accommodation?

Is there any reason why you could not move if you found cheaper accommodation?

When does your tenancy end?

How much notice would you have to give to end your tenancy early?

Do you have any relatives or friends who could help you out?

Could they provide you with accommodation, even if it is only temporarily?

Could they, or anyone who lives with you, help you with your rent or Council Tax (or both)?

Do you, or a member of your family, have any disabilities or health problems?

Is your Housing Benefit less than your rent or your Council Tax Benefit less than your Council Tax?

How Much rent do you pay?

How much is your Council Tax?

Housing Benefit do you receive?

How much Council Tax Benefit do you receive?

Could you pay your housing costs before you claimed Housing Benefit or Council Tax Benefit?

Has someone you lived with recently died?

Your relationship to the person who died:

Do you have any rent arrears?

If yes, please tell the amount and provide evidence (for example, a rent statement or a letter from your landlord).

Do you have any other debts, such as hire purchase, loans, fines and so on?

If yes, please give full details.

Do you or your partner have any savings, investments or property?

“(For Example, bank, building society or post office accounts, shares, unit trusts, ISA’s, Premium

Bonds, National Savings Certificates or Interests/Dividends received from investments or savings)

If yes, please give full details of all the above.

Do you have any savings or property (including holiday homes or timeshares) abroad?

If there is anything else you think we should know, give details

What date do you want to award a Discretionary Housing Payment from?

Please show the amounts of income and spending for you and your partner (the person you are married to or live with as if you were married).

Income You

How much? Your partner

How much? How often?

Child Benefit

Child Tax Credit

Contribution from lodgers and grown-up children

Incapacity Benefit

Income Support or Jobseeker’s Allowance

Maintenance or Child Support

Other (including any gifts or loans from family or friends)

Other state benefits


Wages or salary

Working Tax Credit

Spending You

How much? Your partner

How much? How often?


Bank loans

Car costs

Catalogue repayments



Court fines

Credit card payments

Gas and electricity

Grocery shopping (including

food, toiletries and cleaning materials)

Ground rent or service charge



Mobile phone

Payments to an endowment policy

Phone (landline)

Public transport

Rent or mortgage repayments

(before benefits)

Satellite television

School meals and meals at work

Second mortgage or secured loan

Social Fund loan

TV and video rental

TV licence

Water rates

Other – please give details

You will sign a disclaimer.

I confirm that the information I have given is correct and complete.

I understand that I could be prosecuted if I have given false information.

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

I agree that you can make enquiries to check the information I have given and that you may use this information to collect Council Tax and rent if necessary.

You will sign the document and date it

Your signature & Your partner’s signature


Would you like to provide with any additional information: