Application for Financial Assistance
Disabled Adaptions, Work to eradicate Below Tolerable
Standard Housing & Housing Improvements
For Office Use Only
Reference Number
EAC /
Disabled Adaptation (DA)
Below Tolerable Standard Housing (BTS)
Housing Improvement Programme (HIP)
Do you, due to health issues, require assistance
completing this paperwork?
Section 1
General
1A
Address of the property where work is to be done.
Please include the flat number if applicable.
1B
Your details (the applicant)
(Tick one box)
Mr
Mrs
Miss
Ms
Surname Date of Birth
Forename(s)
Address
Phone (Day / Evening)
Phone (Mobile)
Are you disabled?
Y
N
Are you registered blind?Y
N
1C
Who owns the house where work is to be done?
If there are joint owners, please provide details in the ‘Additional Information’ panel at the back of this leaflet.
Owner’s Name
Owner’s Address
Phone (Day / Evening)
Phone (Mobile) Email Postcode Postcode D: M: E: D: M: E: Postcode
3
1D
If someone else is dealing with this application
on your (the applicant) behalf, please give their details.
Name
Address
Relationship to you
Phone (Day / Evening)
Phone (Mobile)
Section 2
About the House
2A
What sort of property is it?
Please tick one box.House: Detached Semi-detached Terraced
Flat: Tenement High-rise 4-in-a-block
Other Please describe
2B
Please give a brief description of the planned works
2C
How much will these works cost?
Cost of work VAT on work
Professional fees VAT on Professional fees
TOTAL
You will need to provide full specifications for the work and estimates of the costs, including professional fees.
Postcode
D:
M:
Section 3
You and the House
3A
What is your connection with the house?
Agricultural and crofting tenants are treated as owners for the purpose of this form. If this applies to you, please answer as if you were the owner.
Owner Tenant Life-renter Other Please describe
Section 4
Income
4A
Do you have a partner who normally lives with you?
Yes What is your partners name?
Please include your partners income and circumstances in completing this part.
No Please include only your income and circumstances in completing this part.
4B
Do you or your partner (where applicable)
receive any of the following benefits?
Income Support Income-based Job Seekers Allowance
Gaurantee element of Pension Credit Employment Support Allowance
4C
How much did you receive in earnings from employment
and/or self employment in the past year?
Enter the gross amount, minus income tax and NI contributions.
4D
How much did you pay over the past year in contributions
to occupational pensions (deducted from your pay) or
personal pensions, including stakeholder pensions and
retirement annuities?
You
Your Partner
Employment £ £
Self Employment £ £
You
Your Partner
Occupational £ £
5
4E
How much income did you receive from savings and
investments, including annuities, unit trusts, shares etc.
over the past year?
Include all interest paid to any accounts, net of tax, even if it was re-invested.
4F
How much did you receive over the past year from
occupational pensions, pesonal pensions annuities, or state
second pensions (S2P, or SERPS)?
Do not include Pension Credit, or any war widows’ pensions.
4G
If you let any property to someone else, including letting
rooms in your own home, what was the net taxable income
from the letting over the past year?
Enter the amount after subtracting expenses which are deductable for income tax purposes.
4H
If you receive maintenance from anyone for your own
support or to support a child you are responsible for, what
was the total amount received over the past year?
Do not include benefit payments or any payments from a local authority for looking after a child placed with you for fostering or adoption.
You
Your Partner
Income from Savings and Investments £ £
You
Your Partner
Income from Pensions £ £
You
Your Partner
Income from Rents £ £
You
Your Partner
4I
If you receive Housing Benefit, what was the total amount
received over the past year?
4J
How much did you pay in rent or mortgage payments over
the past year, for your own home?
Include payments for any endowment policy or other investment or insurance products you are required to pay to stay in your home. Do not include other amounts for services, bills, additional insurance or council tax.
4K
How much did you pay in rent or mortgage payments,
as above, for any other house where a member of your
family lives?
Only include payments which you are contractually required to make.
4L(i)
Were you or your partner responsible for any child under
16, or any young person between 16 and 21 and in
full-time education, for any part of the past year?
Please tick one box and follow the instructions alongside.
No Please go to question 4M.
Yes Please complete the details below.
4L(ii)
Please list the name and date of birth of each child or young
person in the table below, and tick if they receive Disabled
Living Allowance (DLA) or are registered blind
Continue on a separate sheet if necessary.
Child/Young Person’s Name
Date of Birth
DLA / Blind
You
Your Partner
Housing Benefit £ £
You
Your Partner
Mortgage/Rent £ £
You
Your Partner
7
4L(iii)
If the situation changed during the past year for any of the
children listed in question D12b, please give details of the
changes in the table below, showing the child or young
person’s name and the relevant dates.
4M
Are you or your partner registered blind, or receive any of
the benefits listed below?
Please answer YES or NO in each box.
Name
U16/U2 Student
DLA/Blind
Eg. Mary Smith 2 Nov 02 - 27 Jun 03 2 Nov 02 - 27 Jun 03
You
Your Partner
Registered Blind
Disability Living Allowance
Disability element of Working Tax Credit Disabled Person’s Tax Credit
Severe Disablement Allowance Incapacity Benefit
Mobility Supplement Attendance Allowance
Section 5
Ethnic Monitoring Form
The information requested on this form will help us to make sure we provide Council services fairly to all members of the community. If you prefer not to answer any of the questions, it will not affect the progress of you application. However, we will be able to provide more help with your application if you let us know of any particular needs.
5A
What is your ethnic group?
Choose one section from A to E and tick one box which best describes your ethnic group or background.
(i) - White
Scottish English Welsh Northern Irish British Irish Gypsy/Traveller Polish
Other Please state
(ii) - Mixed or multiple ethnic groups
Any mixed or multiple ethnic groups
Please state
(iii) - Asian, Asian Scottish or Asian British
Pakistani, Pakistani Scottish, or Pakistani British Indian, Indian Scottish, or Indian British
Bangladeshi, Bangladeshi Scottish, or Bangladeshi British Chinese, Chinese Scottish, or Chinese British
9
(iv) - African, Caribbean or Black
African, African Scottish, or African British
Caribbean, Caribbean Scottish, or Caribbean British Black, Black Scottish, or Black British
Other Please state
(v) - Other Ethnic Group
Arab
Other Please state
5B
Would you prefer to receive information about this
application in a language other than English?
Chinese Punjabi Urdhu Polish
5C
Would you prefer to receive information about this
application in an alternative format?
Large Print Braille Audio Tape Computer disc
Section 6
Applicants Declaration
All applicants must sign below.
In order to process your application, East Ayrshire Council requires certain information from you, as detailed in the application form. This information, which may include details of your occupation, financial and ownership details, will be processed by us in accordance with the Data Protection Act 1998.
This form gives us permission to share information which you have provided in your application form with other Council departments or to contact external agencies if we feel the need to verify the accuracy of the information provided by you on your application form.
In the absence of your specific consent, as indicated below, we may contact you and ask you to provide supporting evidence of any details contained in your application before we can process your application fully.
Declaration
This is my application for financial assistance towards the costs described in my application form.
I can confirm that the information provided by me in this application is, to the best of my knowledge, true and accurate. I understand that if I make a false declaration knowingly this could amount to a criminal offence for which I could be prosecuted.
I understand the Home Aid team of East Ayrshire Council will make relevant enquiries with other Council departments and external agencies such as my bank and building society, in order to request information to verify the details on my application for financial assistance. I consent to other Council departments sharing information held by them to aid my application and hereby authorise East Ayrshire Council to make further enquiries with external agencies which are necessary in order to verify the information provided by me in connection with my application.
Signed Applicant
Date
Print Name
Signed Applicant
Date
11
Addtional Information
Use the space below to provide any further information in support of this application. Please reference question numbers.
igned and pr od uc ed b y Eas t A yr sh ir e Counc il D es ign S ec ti on © 2 0 1 0 JB/ 0 2 /1 0 BB Housing Services Civic Centre, Kilmarnock KA1 1HW Tel: 01563 576661 or 01563 576662
E-mail: [email protected]
This document is also available, on request, in braille, large print or recorded on to tape, and can be translated into Chinese, Punjabi, Urdu, Gaelic and Polish. Ma tha sibh airson fiosrachadh fhaighinn ann an cànan sam bith eile, cuiribh brath thugainnaig an t-seòladh a leanas.
Dokument dost pny jest równie w alfabecie Braille’a, w wersji z powi kszonym drukiem lub w formie nagrania d wi kowego na kasecie. Na yczenie oferujemy tak e tłumaczenie dokumentu na wybrany j zyk.