Deferred Payment Scheme Application Form

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Deferred Payment Scheme

Application Form

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How to complete this

application form

You will need to fully complete the form starting on page three of this booklet.

Please ensure you have read the leaflet ‘Information on Deferred Payment Scheme’ available on

leeds.gov.uk/deferredpayments, to ensure you meet the criteria for the scheme.

We will also need to see original documents to help with your application. (See Section 7)

We will need to verify the

documents outlined in

Section 7 in two ways:

1. From a Leeds City Council member of staff. To book an appointment, please call

0113 247 8867. We will photocopy your original documents.

2. If this is not convenient, we require a professional individual (employer or solicitor) to

confirm who you are and that they have seen the original documentation. The application and copies of your

documentation can then be forwarded to:

Financial Management Adult Social Care Finance Community Care

4th_{Floor West}

Civic Hall Leeds LS1 1UR

For enquires about this form, or the deferred payment scheme please call,

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Section 1 Details of the person applying for the Deferred Payments

Scheme (the person in care)

ESCR Number (Local Authority Unique Ref No. – to be quoted on all correspondence) Title (e.g. Mr, Mrs, Ms) First Name(s) Last Name Date of Birth Address (including postcode) Email Telephone number

Are you: Single Married Divorced

Separated Widowed Civil partnership

Section 2 Details of representative of person applying for the

Deferred Payments Scheme (if applicable)

Title First Name(s) Last Name Address (including postcode) Telephone Email

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Relationship to person named above

Do you have legal authority to act on behalf of the person named in Section 1?

Yes No

If yes, please give details:

Power of Attorney Deputy or receiver Enduring of Lasting Power of Attorney Solicitor

Please attach documents confirming legal arrangements

Section 3 About the property

Please give the full address of the property (including

postcode) What is the property’s current value?

£ Do you have a mortgage or other secured loan

on the property? Yes No

If yes, what type of mortgage or loan do you have?

Repayment Endowment Interest Only

If you have another type of loan please give details:

How much do you pay each month (include any endowment or insurance premium) £

Name of mortgage lender Account number

Date of mortgage agreement

Amount of outstanding mortgage £

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Please attach documents confirming mortgage details

Does anyone else have an interest in the property with you?

Yes No

If yes is this part of an equity release scheme? (you will be required to provide

documentation to verify this)

Yes No

If yes, please give their details and their interest:

Name Address Interest in property

Please attach documents confirming details

What type of property is it?

Detached house Semi-detached house

Terraced house Bungalow

Flat Other

If other, please give details:

Does anyone live in the property? Yes No

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Section 4 About the property expenses

Type of Expense How much? How often? (Weekly, monthly, yearly)

Service Charge £

Fuel Charge £

Ground Rent £

Building Insurance – this is essential £

Other charges £

£ £

Please attach documents confirming expenses

Section 5 Property Maintenance

You will need to maintain the property and land, including gardens and outbuildings. This means the property will need to be insured annually and utility bills will need to be paid. It may also include renting the property out. Please explain how do you intend to maintain and upkeep the property, including whether you plan to rent it out.

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Section 7 Checklist for Documentation

Please check and ensure you have provided documentation requested on this form. Details of legal

representative (Please provide Enduring/ Lasting Power of Attorney or letter from Office of Public

Guardian detailing who has been appointed as Deputy for service user)

Death certificate for a named deceased party on land registry or title deeds

Joint or other interests in the property

Property expenses including Building Insurance

Copy of equity release agreement (if

appropriate)

Photo identification Land Registry or title

deeds

Mortgage details and consent form

3rd Party Top Up declaration (if appropriate)

Property Valuation

Please remember, original documentation verification is required. Please call

0113 2478867 to arrange for appointment or alternative certification. If you have already provided the above documents to a Finance Officer from Community Care Finance, you will not need to provide these again.

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Section 9 Declaration

I wish to make an application under the Deferred Payments Scheme.

I understand that acceptance of any application under the scheme is at the discretion of Leeds City Council, subject to you meeting the eligibility criteria and the local authority being able to obtain adequate security. The deferred

payments will not take effect until a formal agreement is entered into.

I confirm that I own /part-own (please delete as appropriate) the property specified in Section 3. I authorise Leeds City Council to check legal title to the property.

When the agreement begins, I agree to a legal charge being placed on the property specified in Section 3 and agree to pay the legal costs of Leeds City Council.

I agree that I shall be responsible for payment of the weekly contribution to the cost of my care that I am assessed to make under the regulations specified in the Care Act 2014 regulations regarding charging from my income and other capital

I confirm that I and all other persons who occupy or have an interest in the property specified in Section 3 have been told of the need to take independent legal and financial advice before I enter into an agreement under the Deferred Payments Scheme.

I confirm that the information given on this form is true and accurate to the best of my knowledge.

Leeds City Council will use the information you have provided for the following purpose of deciding on the application for a deferred payment and the financial assessment of the person’s contribution. No personal information you have given us will be passed on to third parties for commercial purposes. [Our policy is that all information will be shared among officers and other agencies where the legal framework allows it, if this will help to improve the service you receive and to develop other services.]

You have the choice to pay for fees and interest as it accrues throughout the agreement or you can pay at the end and the fees will be added to the debt outstanding. Please note that interest will be added to any debt outstanding. Please indicate below your intention.

I wish to pay set up fees on successful application (An invoice will be issued when we have a signed agreement).

I wish to pay interest and ongoing fees six monthly (in arrears). (An invoice will be issued with the six monthly statements).

I wish for all fees and interest to be accrued with the debt outstanding until the end of the agreement.

Your full name:

Your signature: Date:

If you are signing on behalf of the person applying to use the Deferred Payments Scheme, you must be the person named in Section 2, and have legal authority to act.

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For general information about Adult Social Care telephone customer services on 0113 222 4401.