Claim form for Discretionary Housing Payment
Benefit Department, North Norfolk District Council, Holt Road, Cromer, Norfolk, NR27 9EN
Telephone (01263) 516349 Minicom (01263) 516005 Fax: (01263) 515042
Name & Address:
Reference Number:
You will need to quote this number when you contact us.
Date Sent
Return by
Officer’s Initials
Date received in office
What is a Discretionary Housing Payment (DHP)?
A DHP is additional financial assistance which is available for people who receive Housing Benefit and have a need for
further help to meet their rent payments. If you are receiving Housing Benefit and your level of entitlement does not
meet the whole of your rent charge, this means you have a rent shortfall.
To apply for a DHP to help with your rent shortfall, you will need to complete the attached application form.
In some circumstances, a DHP can be considered for payments of rent in advance, rent deposits and some other costs
associated with housing, such as removal costs and rent arrears. If you wish to apply for a DHP for these types of
housing costs you will need to contact our Housing Options team on 01263 516375 to discuss your housing needs and
your eligibility for seeking assistance from the DHP scheme.
DHP’s are paid from a fund which each Local Authority has allocated to it by the Department for Work and Pensions in
each financial year. North Norfolk District Council will not spend more than the funding it receives. The fund is
administered by each Local Authority in accordance with its policy and procedures and in line with guidance from the
Department for Work and pensions.
A DHP is not intended to be a long term ongoing payment. It is usually intended as a short term measure to help you
whilst you take steps to improve your circumstances. An award can be made for all or part of your rent shortfall over a
period of time. An award may be conditional. If an award is made on one occasion there is no assurance that a
subsequent application will be successful.
As this is a discretionary scheme, there are no rights to appeal against the refusal of an award, the sum of any award or
the period over which any award is granted. However, we do wish to ensure fair and consistent treatment. If you feel
that our decision is incorrect, you can request that the decision is looked at again. Your request must be made in writing
within 21 days of the date of our decision.
Decisions are made jointly between the Benefits Department and the Housing Options Team. By making an application
you are agreeing that information can be exchanged between the Benefits Department and the Housing Options Team.
How will we decide whether to make an award?
Details of your income and expenditure are required in order to make an assessment of your income and expenditure.
We will take in to account all of your income, even those incomes normally ignored for Housing Benefit
purposes. We will take into account the rent charges, how long you have had the tenancy, your family household
composition, the ages, sex and circumstances of those in the household etc., including health and disabilities. We will
liaise with the Housing Options Team to gather some knowledge of the rental market in the area in which you live.
Where appropriate we will ask that team to contact you to consider alternative forms of help and advice. We may ask
you and/or your landlord, where appropriate, for additional information.
What is it that DHPs cannot help with?
You cannot receive a DHP for ineligible service charges such as heating, lighting, fuel, insurance, meals etc.
You cannot receive a DHP for Council Tax (but Council Tax and arrears of Council Tax may be taken in to account when
assessing your expenditure).
For help with understanding this document, or to receive it in a different format or language, please phone
01263 516349 or email benefits@north-norfolk.gov.uk
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Who can apply for Discretionary Housing Payment?
If you receive Housing Benefit and you have a rent shortfall you may apply for a DHP.
Some examples are:



You are the tenant of a private landlord:

You receive Housing Benefit, but this is limited to the maximum Local Housing Allowance (LHA) rate, leaving
you with a rent shortfall;

Your Housing Benefit is reduced because you have non-dependent deductions from your benefit;

You do not receive full Housing Benefit because your income affects your award;

You are a single adult, under 35, whose Housing Benefit is restricted to the shared accommodation rate of
LHA.
You are the tenant of a registered social landlord (Housing Associations such as Victory Housing Trust,
Guinness Trust, Broadland Housing Association, Flagship Housing Group etc.)

You are under state pension credit age and you have more bedrooms than are needed for the number of
people in your household so you are affected by the under occupancy restriction;

You have a disabled person as a member of your household and you have more bedrooms than needed for
the number of people in your household, but your property has been specifically designed or adapted for
disabled use.
Any tenant of either a private landlord or of a registered social landlord

You risk becoming homeless due to the rent arrears and/or debt and you’re on a low income;

You and your partner require separate bedrooms for medical reasons.
What if you think you need more bedrooms than Housing Benefit is allowing for?
If you are in the following circumstances you may be allowed extra Housing Benefit without having to
claim a DHP.

If you or your partner require overnight care. If this care is provided by a carer who sleeps over, using an
additional bedroom, but they normally live elsewhere, then this may be something which can be considered
without requiring you to apply for a DHP. You should contact this office.

If you have a severely disabled child who cannot sleep in the same room as their siblings and you receive the
higher or middle rate care component of Disability Living Allowance for that child, this is something which can be
considered without requiring you to apply for a DHP. You should contact this office.

If you are a foster carer and you need extra room(s) because of this, you should contact this office.

If you have a son or daughter who normally lives with you in the Armed Forces, but they are currently deployed
on operations, you should contact this office.
Please retain these notes for your information. Please complete and return the attached form
as soon as possible. If you have any questions regarding this form please contact the Benefit
Department on 01263 516349 or email benefits@north-norfolk.gov.uk
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Part 1 About you and your partner
You 
Your partner 
Surname or Family name
First name or names
Any other surname or Family
names you have used
Title
(Mr, Mrs, Ms etc.)
Address that you wish to
claim DHP
including Postcode
When did you move to this
address?
If you have not moved in yet,
tell us when you expect to
move in. You must tell us
when you have actually moved
in.
Your contact details
This may help us deal with
your claim more quickly.
Landline:
Landline:
Mobile:
Mobile:
Email:
Email:
Are you single, under 35 and have spent
three months or more in a homeless
hostel or a hostel specialising in
rehabilitation or resettlement and
accepted a support service?
If ‘Yes’ please provide the name and
address of the hostel and the dates you
stayed there.
Are you subject to active multiagency management under Multi
Agency Public Protection
Arrangement?
Yes
 

From:
Yes


No


No

To:
 


If ‘Yes’ please provide their details.
1
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Part 2 About where you live
What sort of building do you live in?
Tick one box only.
Detached house
Semi-detached house
Terraced house
Maisonette
Bungalow










Flat in a house
Flat in a block
Flat over a shop
Bedsit or rooms
Hostel
Board and lodgings
Hotel
Caravan
Mobile Home
House Boat
How many bedrooms do you
have?
Give the names of everyone
who is resident in the
property?
If there are more than 8 people
living with you please use a
separate sheet of paper to tell
us and tick this box

Name
Name
Name
Name
Name
Name
Name
Name
Do you occupy the whole property?
Yes
 



Yes
 


No
No

If ‘No’ please explain.
Do you or any member of
your household suffer from
any disability or other health
problems?
If ‘Yes’ please tell us their
name/s and explain the
disability or health problem.
We may need to see
supporting evidence of this
e.g. letter from a Doctor,
specialist or social worker.
2
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





Part 2 About where you live continued
Has your home been
adapted for disabled use?
Yes
 



No

Yes
 



No

 



If ‘Yes’, who was this for and
what is the nature of those
adaptations?
Is anyone in your
household expecting a
baby?
If ‘Yes’, who is expecting the
baby and what is the baby’s
due date?
Are you expecting any changes in
your circumstances which will
mean you will be able to pay MORE
of your rent in the near future?
Yes
No

If ‘Yes’ explain what the changes are
and how it will lead to you being able
to pay more of your rent?
Are you expecting any changes in
your circumstances which will
mean you will be able to pay LESS
of your rent in the near future?
Yes
 



No

If ‘Yes’ explain what the changes are
and how it will lead to you being able
to pay more of your rent?
3
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Part 2 About where you live continued
What is your landlord’s full
name and address inc
postcode?
(By landlord, we mean the person
or organisation who owns the
property you live in).
Do you have rent arrears?
Yes
No
If you are a private tenant, have
you tried negotiating a lower
rent with your landlord?
If ‘Yes’ by how much and how many weeks?

Yes
 



No
£
wks

If ‘Yes’ what was the outcome?
If ‘No’ why not?
Have you looked for other
accommodation that is smaller
and/or with a lower rent?
Yes
No

If ‘Yes’ what was the outcome?
If ‘No’ why not?
Are there any reasons that
prevent you from moving?
Yes
No
If ‘Yes’ what are the reasons?
If ‘No’ how far would you be
prepared to move to find
cheaper/smaller accommodation?
4
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
Part 3 Discretionary Housing Payment (DHP)
If a DHP was to be awarded
how much do you think you
will need each week/month?
£
If a DHP was to be awarded
how long will you need this
award for?
Number of Week
each Week
or
£
or
Number of Months
each Month
A DHP is usually only
awarded for a short period of
time. What action are you
taking to resolve the problem
and meet your housing costs
on a long-term basis?
Has there been a change in
your circumstances which has
led to you putting in a claim
for DHP?
Yes
 



No

If ‘Yes’ what was the change
and when did it happen?
5
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Part 4 Income
You must list ALL income as NO income is ignored for DHP purposes.
You 
Your partner 
Benefits, Pensions, Allowances and
Wages
Yes

How
Much?
Adoption Pay
Armed Forces Independence Payment
Attendance Allowance
Bereavement/Widows Benefit
Carer’s Allowance
Child Benefit
Child Tax Credit
Contributions from other household
members
Disability Living Allowance Care
Disability Living Allowance Mobility -
Is this for a Motability scheme?
Employment & Support Allowance
Fostering Allowance
Income Support
Industrial Death Benefit
Industrial Injuries Benefit
Incapacity Benefit
Jobseeker’s Allowance
Maintenance/CSA received
Maternity Allowance
Pension Credit
Personal Independence Payment
Private Pension
Self-employed income
Severe Disablement Allowance
State Retirement Pension
Statutory Maternity/Paternity Pay
Statutory Sick Pay
Student loans/grants
Universal Credit
Wages – after deductions
War Pension
War Dependant’s Pension
War Widow’s Pension
Widowed Parent’s Allowance
Working Tax Credit
Other- please list below
6
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How
often?
Yes

How
Much?
How
Often?
Part 5 Capital
Please tell us about any cash, Current accounts and Savings accounts you have with a Bank or Building Society or Post
Office accounts, Premium Bonds, National Savings Certificates, Stocks, Shares and property. Please answer these
questions for yourself and your partner. Please include empty and overdrawn accounts, whether in a single name or
jointly held.
Do you and/or your partner have any Bank,
Building Society or Post Office accounts?
Yes
No
Please list these below

All Bank, Building Society or Post Office accounts
Bank/building
Society/Post office name
Sort Code
Do you or your partner have any Investments, Bonds, Shares
or National Savings certificates? If ‘Yes’ please list these below
Type of saving or investment
Name of account
holder
Account number
Name of company held in
Yes

Number of shares/units
held

Balance
No

Approximate value
7
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Part 6 Expenditure/Outgoings
Yes

How Much?
Rent – the shortfall that you pay
Council Tax – the shortfall that you pay
Buildings/Contents Insurance
Life Insurance
Other Insurance
Water
Gas
Electricity
Coal/Oil/Wood/Other
TV Licence
Telephone
Mobile Phone
Internet
Satellite/Digital TV
Food
Other Household shopping (e.g. cleaning)
Pet food and expenses
Pension Contributions
Car - Road Tax
-
Insurance
-
MOT & Repairs
-
Petrol/Diesel
-
Hire purchase
-
Breakdown or Recovery cover
Public Transport/Taxis
Maintenance/CSA
Childcare Costs
School Meals
Children’s Pocket Money
Clothing and Footwear
Prescriptions
Opticians/Dentist
Entertainment
Alcohol
Cigarettes/Tobacco
Newspapers/Magazines/stationary
Other expenses - please list below
8
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
How Often?
Office Use only
Part 7 Arrears and Credit commitments
Yes

How Much?

How Often?
Office Use only
Council Tax Arrears
County Court Judgements
Court Fines
Credit Card Payment
Credit Card Payment
Credit Card Payment
Credit Card Payment
Hire Purchase Payments
Maintenance/CSA Arrears
Rent Arrears
Telephone Arrears
TV/Internet Arrears
Utility Arrears – Gas/Electric/Water
Other – Please list below
Part 8 Anything else you need to tell us
Use the box below to tell us anything else you think we should know about. Use a separate sheet of paper and attach it
to this form if you need to.
9
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Part 9 Third Party Consent
Please complete this section if you would like to give us permission to discuss your claim with a third party (eg a support
worker, relative, friend, carer, etc).
Name and address of third party:
Contact number:
Consent Declaration
I agree that the Benefits department at North Norfolk District Council can disclose relevant information when requested by
the third party listed above concerning my claim for Discretionary Housing Payment. The information provided will be
limited to:
 The progress of my claim.
 The assessment of my claim.
 The calculation of my entitlement.
I understand I can withdraw this consent at any time. This consent will continue until either the Council, the third party
listed above or I choose to withdraw it.
Where further information is required to make a decision on my claim, the Council can advise the third party listed above
that the information has been requested to speed up the collection of any such information.
Signing or failing to sign this consent will in no way affect the final result of my application for Discretionary Housing
Payment.
I consent to the disclosing of relevant information concerning my claim for Discretionary Housing Payment by the council
to the third party named on this form.
Signature of claimant: ………………………………
Date: …………………
Signature of partner: ………………………………..
Date: …………………
Part 10 Declaration
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 know that I must let you know in writing about any change in my circumstances which might affect my claim.
I agree that you will use the information I have provided to process my claim for Discretionary Housing Payment. You
may check some of the information with other sources as allowed by the law.
I understand that you may use any information I have provided in connection with this and any other claim for DWP
benefits that I have made or may make. You may give some information to third parties who include employers,
landlords, government departments, local authorities and private sector companies such as banks, as well as
companies that assist us in fraud detection and prevention such as credit reference agencies. You may contact my
employer to obtain evidence of my earnings.
I authorise you to use the information I have given on this form and on any supporting documents to manage Council
Tax and other council activities.
Signature of person claiming
Date

Partner’s signature
Date
10
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