Revenues and Benefits Service
Wakefield One, PO Box 700
Burton Street, Wakefield WF1 2EB
Tel: 0845 8 504 504
Discretionary Housing Payment
Application form
In certain cases Wakefield Council may be able to offer extra help with your housing
costs if you have a shortfall between your rent and Housing Benefit. We can also
help with removal costs, rent in advance and rent deposit.
The Government has given us a limited amount of money to help people who meet
certain criteria and need more financial help with their housing costs. We call these
Discretionary Housing Payments.
Discretionary Housing Payments are not benefit payments. They are separate
payments the Council can make if it thinks people need extra help with housing
costs. Awards are usually short term, and are designed to help make up your
shortfall while you look to improve your financial circumstances and make up your
shortfall yourself.
For an application to be considered you must fully complete this form, including
the section on expenditure. You may be required to provide evidence to
support your application, but please do not send any original / valuable
documents through the post.
If you think you might need extra help with your housing costs, please fill in this
application form, and return it to:
The DHP Team
Wakefield Council Revenues and Benefits Service
Wakefield One
PO Box 700
Burton Street
Wakefield
WF1 2EB
Please complete this form in blue or black in and print your answers clearly. If you
have a partner, please ensure you include all income and expenses for them.
If you would like any help to fill in this form, please call us on 0845 8 504 504
Section 1: About you
Housing Benefit reference number (if you have it):
Surname
First name
Address
Telephone
Please ensure you include a telephone number we can contact you on, as we may need to
discuss your application with you.
Please tick if any of the following apply to you:
I consider myself / my partner to be disabled
☐
I / my partner have a regular, non-resident overnight carer
☐
I am a registered Foster Carer
☐
I live in a property significantly adapted for a member of my household
as a result of disability
☐
☐
I have a disabled child
I have a grown up son/daughter currently at University / in the Armed
Forces who comes home during holidays
☐
Do you need help with your:
Rent
☐
Rent in advance
☐
Deposit for a tenancy
☐
Removal costs
☐
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Are there any children living with you?
Yes
☐
No
☐
Yes
☐
No
☐
If yes, how many?
Are there any other adults living with you?
If yes, how many?
Do you share custody for any children who stay with you on a part-time basis?
Yes
☐
No
☐
If yes, how many?
If someone has helped you fill in this form, please tell us their name, contact details
and why they have helped you
Section 2: Help with your rent
Landlord’s name:
Landlord’s address:
Landlord’s
telephone number:
How much is your full contractual rent?
£
every
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How much help do you feel you need per week, and when do you need this from?
£
/
From
/
If you need an award from a date earlier than today, please tell us why you did not
apply earlier
Are you in rent arrears?
☐
Yes
If yes, how much do you owe?
☐
No
£
Have you been issued with a ‘Notice to quit’?
Yes
☐
No
☐
Could you afford your rent when you moved in?
Yes
☐
No
☐
Have you asked your landlord to reduce your rent? Yes
☐
No
☐
If your landlord has agreed to reduce your rent, how much is the new agreed rent?
£
Would you be willing to move to alternative, more affordable, accommodation?
Yes
☐
No
☐
If no, why not?
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Section 2b: Help with a rent deposit
Address you are
moving to:
Date you are
moving in:
Landlord’s name:
Landlord’s address:
Landlord’s
telephone number:
Do you give permission for the Council/Revenues and Benefits service to contact
the landlord should any details need to be verified?
Yes
☐
No
How much is required for your deposit?
☐
£
We will need proof of this from your new landlord
Do you have any money to be able to pay towards the deposit yourself? If so,
please tell us the amount you can afford to pay
£
What steps have you taken to try and get this money?
Are you due to have a deposit or rent in advance for your current tenancy returned
to you?
Yes
☐
No
☐
If yes, how much do you expect to receive, and when will you receive this?
£
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If no, please explain why:
Have you now, or in the past received similar assistance through a rent deposit
guarantee scheme or anything similar?
Yes
☐
☐
No
If yes, when did you receive this and from where?
Section 2c: Help with removal costs
How much have you been quoted for removal costs?
£
Please note: Removal costs will be paid directly to the company/supplier assisting
with removal and we need to see an invoice.
Section 3: Your Income
Please list all of your income details.
Income
Amount received
Jobseekers Allowance/Income
Support
Employment and Support
Allowance
Pension Credit
Wages (take home pay)
Child Benefit
Child Maintenance
Working Tax Credits
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How often received
Child Tax Credits
State Retirement Pension
Disability Living Allowance –
Care
Disability Living Allowance –
Mobility
Attendance Allowance
Carer’s Allowance
Income from savings
Board/income from other
adults living in the property
Other:
Other:
Other:
Other:
Any ‘Other’ income, please ensure you tell us what this is for
Section 4: Savings and Capital
Please give details of any Bank or Building Society Accounts you have and the
current balance (even if you are overdrawn, please tell us how much you are
overdrawn by). Ensure you include details of any savings, ISA’s, Tessa’s/Premium
Bonds you hold:
Name of Bank / Building Society /
Savings type
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Amount
Section 5: Your Spending and Outgoings
Please list ALL of your regular and one-off outgoings
Outgoings
Amount paid
Home
Council Tax
Rent
Water Rates / Meter
Gas
Electricity
Home phone
Internet
Mobile phone (Pay As You Go)
Mobile phone (Contract)
TV licence
TV package (e.g. Sky)
Cleaning products
Window/Wheelie bin cleaning
Gardener
Daily newspaper
Other:
Other:
Banking and Insurance
Contents insurance
Life/health insurance
Pet insurance
Overdraft fee
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How often
Outgoings
Amount paid
Food and Drink
Food and Household shopping
Eating out
School lunches
Work lunches
Alcohol
Cigarettes & Tobacco
Other:
Other:
Other:
Travel and Transport
Petrol
Car loan/hire purchase
MOT and Car maintenance
Road Tax
Breakdown Cover
Parking
Public transport/taxi costs
Other:
Other:
Family and Health
Child care
Child maintenance (to expartner)
Before/After school clubs
Nappies / baby extras
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How often
Outgoings
Amount paid
Clothing/footwear
School uniform
Pocket money
Laundry
Dentist
Regular prescriptions
Haircuts
Family days out
Eye tests
Glasses / contact lenses
Carer costs
Course fees
Other:
Other:
One-off’s
Christmas
Birthdays
Holidays
Other:
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How often
Section 6: Debts
Please list any debts you have. If you have multiple debts, you should seek
independent advice about dealing with this before submitting this application.
Debt
Amount paid
Rent arrears
Rent arrears (previous
property)
Council Tax arrears
Housing Benefit
Overpayment
Social fund loan
Bank loan
Credit card
Credit card
Doorstep loan
Doorstep loan
Catalogue
Catalogue
Court costs / fines
Maintenance arrears
Gas arrears
Electricity arrears
Water arrears
Hire purchase
repayments
Hire purchase
repayments
Hire purchase
repayments
Money owed to family /
friends
Other:
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How often
Amount
outstanding
Section 7: Your Health
If you or anyone in your family has a health problem that you think is relevant to your
application, please give details:
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Section 8: Financial hardship
Please use this space to explain why the shortfall in your benefit will cause you
financial hardship, and give any other information you think may help your
application:
Section 9: Declaration
Please read this declaration carefully, then sign and date it.
 I declare that all the information I have given on this form is correct and
complete as far as I know.
 I will tell the Revenues and Benefits Service about any change in my
circumstances that may affect my claim.
 I understand that the Council may need to share the information I have
provided with other agencies
Signed:
Date:
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