Application to Make a Top Up Payment for Residential
Accommodation Charges
This document is to be used for Top Ups of more than £50 per week
Please Return to:
Rochdale Borough Council
Adult Care Services
Floor 3
Number One Riverside
Smith St
Rochdale OL16 1XU
OperationalBusiness.SupportTeam@rochdale.gov.uk
Instructions For Completion:

Please complete this questionnaire in full


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Please write legibly (print if necessary)
Please declare ALL income and expenditure
Please ensure all values are verified by providing supporting documents
Personal Details of the Person To Whom The Top Up Applies
Title: Mr / Mrs / Ms / Miss
First Name(s):
Surname:
Date of Birth:
Name & Address of Care Home:
Personal Details of the Person Making the Top Up
Title: Mr / Mrs / Ms / Miss
First Name(s):
Surname:
Date of Birth:
National Insurance No:
Full Home Address & Postcode:
Dependents (children of 17 and under)
Name:
Date of Birth:
Address:
Name:
Date of Birth:
Address:
Name:
Date of Birth:
Address:
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EMPLOYMENT
Are you employed?
Yes
/
No
What is your Occupation:
Name of your Employer:
Address of Employer:
Income (Gross) from Employment* £________per
________Hourly/Weekly/Monthly (please circle)
How long have you been in this employment:
If presently unemployed, please state the date you became unemployed:
*For salary payments please enclose a copy of the latest 3 payslips
Your Income
How Often?
(Please Circle)
State Retirement
Pension*
Salary
Other income
Week/
Fortnight/ Four
Weeks
Week/
Fortnight/ Four
Weeks
Week/
Fortnight/ Four
Weeks
Week/
Fortnight/ Four
Weeks
Week/
Fortnight/ Four
Weeks
Company & Reference/
Account Number
Amount
Documents
seen by
Officer
£
£
£
£
£
*With all benefit payments, please enclose either the ‘Letter of Award ’(which will be returned) a copy
of the front page of the Benefit Book, or a copy of a bank statement indicating the benefits received.
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Your Spending
How Often?
(Please
Circle)
Amount?
Rent & Ground Rent (less
Housing Benefit)
Week/Month
£
Council Tax
(less CT Benefit)
Week/Month
£
Mortgage Repayment
Week/Month
£
Insurances
Week/Month
£
Food
Week/Month
£
Maintenance Payments
Week/Month
£
Other
Week/Month
£
Your Debts
Company & Reference/
Account Number
Company & Reference/ Account Number
Amount?
Rent or Mortgage
£
Council Tax
£
Utility Bills
£
Bank Loans
£
Credit Cards/
Store Cards
£
Other (Specify)
£
Other (Specify)
£
Your Capital &
Savings
Company & Reference / Account Number
Savings Accounts
Stocks/ Shares
Other (Specify)
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Amount?
£
Number held:
£
£
Documents
seen by
Officer
Documents
seen by
Officer
Documents
seen by
Officer
DECLARATION
As far as I know the information that I have given on this form is true and complete.
If my financial circumstances change I must notify the Council immediately, for
example, if I become unemployed or change jobs.
I am willing to make payment of the top up to the care home for the length of stay in
the accommodation. It is likely that there will be an increase in the top up each
financial year but these will need to be reviewed and are not automatically to be
taken on by one party. This will be discussed with the local authority following a
review of the personal budget.
I understand that if I default on the top-up payment the local authority may take
action against me. This may result in the accommodation being terminated and
alternative accommodation arranged.
The top-up payment must not be derived from the person’s savings or capital unless
it is a property that is subject to the 12-week disregard or the costs of care are being
met through a Deferred Payment Agreement.
The top-up payment must be paid in addition to the assessed contribution.
Print Name:
Signature:
Date:
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