Section 1: Tenant Details	

If your Landlord is a Housing Association, Registered Charity or Voluntary Organisation and you receive care, support or supervision from your Landlord or someone acting on your Landlords behalf you may be entitled to more Housing Benefit.

The care, support or supervision provided by your Landlord or someone acting on their behalf must be more than the minimal support usually provided by a Landlord.  

Please complete this application form and return it to our Operations Team, P.O. Box 5650, Inverness, IV3 5YX. If you require more information or assistance with the completion of this form please telephone 0800 393811 or email Operations.Team@highland.gov.uk.

Tenant Contact Details – Please complete all sections: 

Name:		

Address:	
                                                      Postcode:  	

Telephone: 		

Mobile:		

Email:		

HB Claim Number: 		

Landlord Name:		

Landlord Address:	
                                                                                 Postcode: 	

Please tick:	Housing Association □  Registered Charity □  Voluntary Organisation □	

Who lives in your property with you, please start with your own details: 

Name	Male/
Female	Relationship to tenant	Date of Birth	Age	

Tenant			

					

					

Section 2: Care, Support or Supervision	

Does your Landlord or someone acting on their behalf provide care, support or supervision?								 Yes □      No □   

You must provide evidence that you receive care, support or supervision at your address e.g. your lease or your contract from the care provider. 

Please complete the following:
Who receives care, support or supervision in your household:		

Name of care provider:		

Address of care provider:		
Date care, support or supervision started at your current address:		

Section 3: How we collect and use information	

We will use the information you give on this form and any supporting evidence to process your claim for Housing Benefit, and may use this information for Council Tax, Council Tax Reduction, Second Adult Rebate and Scottish Welfare Fund.
The Highland Council is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud and to make sure that the information is accurate. We may also share this information with other Council Services, Agencies, Organisations, Local authorities, Government Departments and other bodies responsible for auditing or administering public funds.
We will not give information about you to anyone else, or use information about you for other purposes, unless the law allows us to.
The Highland Council is the data controller for the purposes of the Data Protection Act 1998.
If you want to know more about what information we have about you or the way we use that information you can email foi@highland.gov.uk or write to the Information Officer, Chief Executive’s Office, The Highland Council, Glenurquhart Road, Inverness, IV3 5NX.

Section 4: Declaration – all applicants must complete section 4	

Please read this declaration carefully before you sign and date this form.

Warning: It is an offence to give false information. If someone has completed this form on your behalf, you must make sure that it has been read back to you in full and you understand everything before you sign the declaration. In the case of a couple, only the Housing Benefit claimant must sign the form below.

I declare the information I have given on this form is correct and complete.

I authorise the Council to check the information I have given and make any necessary enquiries to verify the information on this form and retain a copy.
I understand that the information I have given on this form may be held electronically and may be shared with other sections within the Finance Service and other Council Services and relevant agencies, or used when considering a Discretionary Housing Payment. We may also share this information with Council Tax, Council Tax Reduction, Second Adult Rebate and Scottish Welfare Fund. 
I understand that if I give information that is wrong or not complete or fail to report a change which may affect my benefit I may be prosecuted.

Claimant’s signature: 	
Date: 	

The following section must be completed if the claim form has been filled in by someone else on your behalf. This includes voluntary organisations, an appointee, relative, friend or representative of the Council.

Please print the name of the person who completed the form:		

Their Address:

Telephone number:
		
Please advise why the claimant was unable to complete the form:		

Relationship to claimant:

I declare that I have filled in this form for the person (s) named above in accordance with their instructions and have read this back to them in full before they signed the declaration.

Signature of person 
completing the form 	Date