Application for an Exceptional Hardship Fund Payment

Name:	Benefit Claim Number:
Council Tax Account Number:
Address:	Date of birth:
National Insurance Number:
Email Address:	Nationality:
Home Phone Number:	Mobile Number:
Why are you applying to the Council Tax Exceptional Hardship Fund? (Please tick all that apply to you) I am receiving less support than in previous years I have had a change in circumstances which means I can’t pay my Council Tax I’m in arrears with my Council Tax Other (please specify) _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________
How long do you think you will need additional support for? 1-3 Months 3-6 Months 6-9 Months 9-12 Months
If you are currently absent from your property, please advise why and where you are currently staying. _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________
If there has been a change in your circumstances which has affected your ability to pay your Council Tax, please explain below. _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________
Please explain why you are in financial hardship, or why you would be if an award is not made. _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________
Please provide details of anyone else resident in your property
Name	Date of birth	Relationship to you
Health and Wellbeing Please explain any health conditions you or another member of your household have which you would like us to consider. _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

Financial Assessment Form (You must complete this section) We need to know about all your weekly income and outgoings and details of any savings.
You	Your Partner
Income	Weekly	Monthly	Weekly	Monthly
Net earnings from Employment (including overtime, commission, bonuses, etc.)
Net earnings from Self Employment
Income Support/ Job Seekers Allowance/ Employment & Support Allowance
Universal Credit
Disability Benefits (PIP, DLA or Attendance Allowance. Please include any paid in respect of children)
Carer’s Allowance
Child Benefit
State Retirement Pension
Occupational Pensions
Pension Credit
Any other state benefit (please say which)
Money received from parents/friends
Child Maintenance
Any other income (please tell us what this is)
Total Income

You	Your Partner
Outgoings	Weekly	Monthly	Weekly	Monthly
Rent
Mortgage payment
Council Tax
Food/toiletries/cleaning products
Telephone (landline)
Mobile phone
Insurance (including Life, Home Insurance – buildings and contents)
Water Rates
Gas
Electricity
TV licence
Car expenses (car insurance/road tax/petrol)
Travel costs/ Bus fares
Clothing
Satellite/digital/TV rental
Internet/Broadband
Childcare
Maintenance
Other (please tell us what this is) i.e. Child Support Agency, court fines, income attachments, union subscriptions, Care package payments, etc.
Total Outgoings
Please tell us about any other debts and regular expenses you have, for example Credit /Store Cards, Catalogue Payments, Hire Purchase Agreements, Personal Loans, Court Orders. (We will contact you if we need to see any proof of these)
Name of Creditor and Date Purchased	Balance £	Weekly/Monthly Payment £	What was the Loan/Card used for?
Have you made any enquiries about reducing the amount/s you are repaying? Yes No If ‘Yes’ please tell us what enquiries have been made:

Current amount of capital	You	Your Partner
Bank accounts
Building Society/ Post Office Accounts
Other savings
Total Savings

Part H Declaration Even if someone else has filled in this form for you, you must sign this declaration if you can. Please read this declaration carefully before you sign and date it. I declare that the information I have given on this form is correct and complete. I understand that if I give information that is incorrect or incomplete, you may take action against me. This may include court action. I agree that you will use the information I have provided to process my application for a payment under the Council Tax Exceptional Hardship Fund. You may check some of the information with other sources as allowed by the law. I understand you may carry out checks of other records the Council holds about me to validate the information I have given on this form. I understand that you may use any information I have provided 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 organisations, such as government departments, local authorities and private-sector companies such as banks and organisations that may lend me money, if the law allows this. I know that if I am in receipt of a State Benefit, I must contact you separately to the Department for Work and Pensions to report changes. Signature of person claiming Date Partner’s signature Date
If someone else has filled in this form on your behalf, please say why below and ask them to sign this form. Reason: __________________________________________________________________ Signature Date Print Name:_________________________________________________________________ Telephone :_________________________________E-Mail:___________________________ What is your relationship to the applicant?
Please use the space on the back of this form to tell us about anything else we should consider regarding your application for assistance.

Please use this space to tell us about anything else we should consider regarding your application for assistance.