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East Ayrshire Council
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?
Yes
No
Application Form:Layout 1
Section 1
1A
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General
Address of the property where work is to be done.
Please include the flat number if applicable.
Postcode
1B
Your details (the applicant)
(Tick one box)
Mr
Mrs
Miss
Surname
Ms
Date of Birth
Forename(s)
Address
(if different from A1)
Postcode
Phone (Day / Evening) D:
Phone (Mobile)
E:
M:
Email
Are you disabled? Y
1C
N
Are you registered blind? Y
N
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
Postcode
Phone (Day / Evening) D:
Phone (Mobile)
Email
2
M:
E:
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1D
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If someone else is dealing with this application
on your (the applicant) behalf, please give their details.
Name
Address
Postcode
Relationship to you
Phone (Day / Evening) D:
Phone (Mobile)
E:
M:
Email
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
Professional fees
VAT on work
VAT on Professional fees
TOTAL
You will need to provide full specifications for the work and estimates of the costs, including professional fees.
3
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Section 3
3A
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You and the House
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.
You
Your Partner
Employment
£
£
Self Employment
£
£
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
4
Your Partner
Occupational
£
£
Personal
£
£
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4E
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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.
You
Income from Savings and Investments
4F
£
Your Partner
£
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.
You
Income from Pensions
4G
£
Your Partner
£
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.
You
Income from Rents
4H
£
Your Partner
£
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
Maintenance Payments
£
Your Partner
£
5
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4I
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If you receive Housing Benefit, what was the total amount
received over the past year?
You
Housing Benefit
4J
£
Your Partner
£
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.
You
Mortgage/Rent
4K
£
Your Partner
£
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.
You
Mortgage/Rent
4L(i)
£
Your Partner
£
Were you or your partner responsible for any child under
16, or any young person between 16 and 21 and in fulltime education, for any part of the past year?
Please tick one box and follow the instructions alongside.
4L(ii)
No
Please go to question 4M.
Yes
Please complete the details below.
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
6
Date of Birth
DLA / Blind
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4L(iii)
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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.
Name
Eg. Mary Smith
4M
Page 7
U16/U2 Student
DLA/Blind
2 Nov 02 - 27 Jun 03
2 Nov 02 - 27 Jun 03
Are you or your partner registered blind, or receive any of
the benefits listed below?
Please answer YES or NO in each box.
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
Other similar benefit: Please specify
7
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Section 5
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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
British
Irish
Other
Welsh
Northern Irish
Gypsy/Traveller
Polish
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
Other
8
Please state
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(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
5B
Please state
Would you prefer to receive information about this
application in a language other than English?
Chinese
5C
Punjabi
Urdhu
Polish
Would you prefer to receive information about this
application in an alternative format?
Large Print
Other
Braille
Audio Tape
Computer disc
Please state
9
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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
Print Name
10
Date
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Addtional Information
Use the space below to provide any further information in support of this application.
Please reference question numbers.
11
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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.
Designed and produced by East Ayrshire Council Design Section © 2010 JB/02/10BB
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.
Housing Services
Civic Centre, Kilmarnock KA1 1HW
Tel: 01563 576661 or 01563 576662
E-mail: [email protected]