Customer CareFirst
reference number
Financial Declaration Form
Please return this form to us by
DD
MM
20YY
Before sending this form to us please make sure you have read and signed the
declaration on page 10.
or
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You can choose not to tell us about your financial circumstances. If so, you will only need to fill in pages
2 and 3 of the form and sign the declaration on page 10. You will be charged for the full cost of any
service provided.
The form has numbered sections and colour coded boxes to help you fill it in.
If you are receiving, or about to receive, permanent care in a residential or nursing care home please fill in the
sections that are coloured blue and the sections coloured pink
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OR
If you are receiving, or about to receive, any other care services, including direct payments, temporary respite
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care and day care, please fill in the sections that are coloured blue and the sections coloured green
Please do not fill in the back cover of this form or any boxes coloured yellow . These parts of the form
are for use by Suffolk County Council staff only.
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Please tell us about the services you are getting from Adult and Community Services by ticking the
boxes below that apply to you.
Care in a Residential or Nursing Care Home
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Please enter the name and
address of the care home
My care is
OR
Permanent
Short term / Trial
I am living at home or in Very Sheltered Housing and getting care and / or support
I am getting, or about to get, a Direct Payment to pay for my own care and support
I am getting, or about to get temporary respite care
My services have not yet been set up
Once completed this form is classified as OFFICIAL – SENSITIVE [PERSONAL]
AF1 (10.14)
Section 1 Personal contact details
1A About the person who is getting the service
Mr / Mrs / Miss / Ms / Other (please state)
Title
Surname
Other names in full
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Date of birth
Address
Mobile telephone number
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Email address
Number
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Code
Telephone number
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Postcode
Letters
Numbers
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National Insurance Number
Please tell us how you would like us to contact you
By post
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By Email
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Letter
1B Financial responsibility
(i) Does anyone look after your financial affairs for you?
If No go to Section 2. If Yes please complete this section.
Yes
No
Yes
No
• Court appointed deputyship (property and affairs)
Yes
No
• Appointee status from The Department for Work and Pensions
Yes
No
(ii) Does the person named in this section have:
• Power of Attorney (either Ordinary, Enduring or Lasting - property & affairs)
If you have answered Yes to any of the above please send us the documents confirming this and tick the
appropriate box in Section 8 on page 10.
Please enter here the contact details of the person with financial responsibility (or any other person
you wish to receive your financial correspondence and invoices from us).
Mr / Mrs / Miss / Ms / Other (please state)
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Title
Surname
Other names in full
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Date of birth
Address
For office use only
Telephone number
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/ None
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CareFirst ID
Code
Postcode
Number
Mobile telephone number
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Email address
Your relationship to the person receiving the service
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I give my permission for Adult & Community Services to contact the above person in relation to my
financial affairs.
Signature of Customer (This is the person receiving the care services).
Section 2 Paying full cost of the service
If you do not want to give us any financial information for assessment, or if you have capital above the current
upper limit, you will have to pay the full cost of your services.
If this is the case please tick the box and go straight to Section 8 on page 10.
Please also complete the Direct Debit Instruction
–3–
Section 3 Your income including state benefits and pensions
3A Please enter details of your income in the first column and tell us how often you receive these payments
in the second column. Please do not make any entries in the yellow column.
Please send us evidence for all the entries you make below and tick the appropriate box in Section 8
on page 10.
Your Income
Amount
Benefits, Allowances and Income
£
p
How often do
you receive
this payment?
For office use only
£
p
Initials
Attendance Allowance
Disability Living
Allowance
Care Component
Personal
Independence
Payment
Daily Living Component
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Mobility Component
Mobility Component
State Retirement Pension
Incapacity Benefit / Employment
Support Allowance
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Severe Disablement Allowance
Universal Credit
Income Support
Pension Savings Credit
War Pensions / War Widow(er)’s Pension
1.
2.
3.
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Private or
occupational
pensions – please
tell us who pays
this money to you
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Pension Guarantee Credit
Any other benefits or income (please specify)
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Income from paid work or self employment
Yes
No
Does anyone receive Carer’s Allowance for looking after you?
Yes
No
Do you receive Carer’s Allowance for looking after someone else?
Yes
No
Are you waiting to hear about a benefit claim you have made?
Yes
No
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Do you have a partner who gets any benefits for both of you?
If Yes, please tell us their name and National Insurance Number.
Name
National Insurance Number
If “Yes” please tell us the name of the benefits you have claimed
Date applied for
Please tell us straight away when you are given a decision about the benefit(s) that you are waiting to
hear about.
–4–
Section 4 Capital including savings and investments
If you have capital and investments which total £10,000 or more please send us bank statements or
passbooks for the last 12 months. (Clear copies of these documents are acceptable). Please tick the
appropriate box in Section 8 on page 10.
Yes
4A Do you have money in a bank, Post Office or building society?
No
If Yes please provide details below. If No please go to 4B
Current balance
£
p
Personal
(P) or
Joint (J)
Account holder’s name(s)
or
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Post Office / Bank / Building Society
name
Yes
No
Do you have any other investments, including capital held in a trust or property
(but not the home you are living in now)?
Yes
No
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4B Do you have any other capital or investments? These include ISA’s, PEP’s,
TESSA’s, National Savings Certificates, Premium Bonds, Income Bonds,
Capital Bonds, Government Bonds (including War Stock), Stocks or Shares.
No. of
shares
Type of Investment
Current
Value £
Name of Owner(s)
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Name of Company
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If you have answered Yes to either or both of the above questions please give us details below. If there is
not enough space please tell us about them on a separate sheet. If No please go to 4C.
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4C Compensation Payments.
If you have ever received a compensation payment please tell us how much you received. £
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Please tell us what this compensation was for e.g. War
compensation payment, Japanese POW payment, payment
from the vCJD Trust, personal injury compensation.
Is this compensation amount included in the capital you have told us about?
Yes
No
Yes
No
4D About your current home.
Do you own the property you are currently living in?
If you have answered No please go straight to either Section 5 (for Residential or Nursing Care) or Section 6.
If you have answered Yes are you the sole owner?
Yes
No
If you have answered Yes please go straight to either Section 5 (for Residential or Nursing Care) or Section 6.
If you have answered No please tell us about the other owners below.
Other
persons who
have joint
ownership of
the property
Name
Relationship
–5–
Proportion Owned (e.g. 1⁄2 or 1⁄3)
THIS SECTION IS FOR RESIDENTIAL OR NURSING CARE ONLY
Section 5 About your former home
Please complete the following information about the property owned by you.
Please tell us what type of accommodation you lived in by ticking the relevant boxes.
House
Bungalow
Flat
Other (please specify)
Semi-detached
Detached
Was it: Private rental
Housing Association
Local Authority
Owner occupied
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Was it: Terraced
Full address of your
property
Postcode
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Value of outstanding
mortgage to be paid
(if applicable)
£
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Estimated value if owner
occupied
Name
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Please tell us about
anyone else living in
your former home
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Are any of the above occupants of your former home incapacitated?
£
Relationship
Date of Birth
Yes
No
If “Yes” please give some details in the next boxes
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Name
Details of their incapacity
–6–
Type of benefit being paid
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Do not complete the Direct Debit form if you are living in
a private residential care home. You will need to make your
own arrangements with your care provider.
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DIRECT DEBIT
Please complete the form on the next page.
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Please do not remove the form from this booklet.
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If your financial assessment means that you have to pay towards the costs of your care / personal
budget we will collect your payment by Direct Debit from your bank or building society account.
If your assessment results in you not being required to make any contribution towards the costs of
your care / personal budget we will destroy the Direct Debit form.
If you are unable to pay by Direct Debit details of how to pay for your care / personal budget will
be shown on the first invoice you receive.
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Instruction to your
Bank or Building Society
to pay by Direct Debit
Please fill in the whole form using a ball point pen
Suffolk County Council - Finance
Floor 3, Constantine House
5 Constantine Road
IPSWICH
Suffolk
IP1 2DH
8
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Originator's Identification Number
3
Name(s) of Account Holder(s)
7
1
5
4
FOR SUFFOLK COUNTY COUNCIL OFFICIAL USE ONLY.
This is not part of the instruction to your Bank/Building Society
Customer Name
Bank/Building Society account number
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Home Care Area
Team Name
CareFirst ID
Branch Sort Code
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Name and full postal address of your Bank or Building Society
Instruction to your Bank or Building Society
Please pay Suffolk County Council Direct Debits from the account
detailed in this Instruction subject to the safeguards assured by the
Direct Debit Guarantee. I understand that this Instruction may remain
with Suffolk County Council and, if so, details will be passed
electronically to my Bank/Building Society.
To: The Manager
Bank/Building Society
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Address
Signature(s)
Postcode
Reference (Customer Number)
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Date
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Banks and Building Societies may not accept Direct Debit Instructions for some types of account
This guarantee should be detached and retained by the Payer .
The
Direct Debit
Guarantee
•
This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits
•
If there are any changes to the amount, date or frequency of your Direct Debit, Suffolk County Council will notify you
10 working days in advance of your account being debited, or as otherwise agreed. If you request Suffolk County
Council to collect a payment, confirmation of the amount and date will be given to you at the time of the request
If an error is made in the payment of your Direct Debit, by Suffolk County Council or your bank or building society,
you are entitled to a full and immediate refund of the amount paid from your bank or building society
If you receive a refund you are not entitled to, you must pay it back when Suffolk County Council asks you to
You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation
may be required. Please also notify us.
•
•
•
DDI2
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THIS SECTION IS FOR RESIDENTIAL OR NURSING CARE ONLY
Section 5 About your former home (contd.)
Please give us details of any regular payments you still have to make for your former home.
Amount
Commitment
£
How often do you pay this?
p
Water rates
or
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Sewerage charges
Gas
Electricity
Household insurance
Alarm
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Council Tax (after benefit deducted)
Rent (after benefit deducted)
Other (please specify)
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Mortgage
……………………………...
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If you own any other land or property, apart from the property you have told us about above, please
make sure you have told us about this in Section 4, (Part 4B).
Have you been in hospital as an in patient in the 28 days before you went into
residential or nursing care?
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If “Yes” please tell us the date you were admitted
–7–
Yes
No
Section 6 About where you live
Yes
6A Do you live on your own?
No
If “No” please give us details below of the adults who are living with you
Name
Relationship
Age
Yes
or
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Do you or your landlord get Housing Benefit or Local Housing Allowance?
Do you get any Council Tax relief or Council Tax benefit?
Do you get any money included in your Income Support, income based
Employment Support Allowance, Universal Credit or Pension Guarantee Credit
to help with your mortgage payments?
No
Yes
No
Yes
No
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6B We need to make sure you have enough money to pay essential housing expenses for the property
you live in. If you live in sheltered or Very Sheltered Housing please send us the most recent statement
of your rent and additional charges.
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Please provide details below of the total household expenses
Housing expenses
Total Amount
£
p
How often do
you pay this?
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Council Tax (enter the amount you actually pay after benefit
has been deducted) and tell us how many payments you
actually make each year.
Rent (enter the amount you actually pay after any benefit has
been deducted – but do not include service charges, support
charges or fixed heating charges).
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Mortgage (enter the amount you actually pay after any benefit
is deducted).
£
If this cost includes food please tell us what is included:
Evening meal
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If you pay for board and lodgings, how much do you normally pay each week?
Breakfast
Lunch
6C Accommodation
Please tell us what type of accommodation you live in by ticking the relevant boxes.
House
Bungalow
Flat
Other (please specify)
Is it:
Terraced
Semi-detached
Detached
Is it:
Private rental
Housing Association
Local Authority
–8–
Owner occupied
Section 7 Disability Related Expenses
7A If you have expenses which are related directly to your disability and which are not included in your
personal budget, we may be able to make an allowance towards their costs as part of your financial
assessment. The sort of expenses we can consider are shown below. Please include anything else you feel
we should consider. Please note: You may be asked to provide more information about any of the items
listed. If you are claiming for extra fuel usage or water consumption you must enclose your last 12
month’s bills to support your claim.
Payable to?
(Name / company)
Type of expense
Weekly
Amount
£
For Office use only
Verified
Authorised
Payment for community alarm systems.
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Privately arranged care or support services.
Extra laundry costs. Please tell us how many loads
you have to do each week and why in this box. 
Extra cost of a special diet. Please tell us why this
is needed in Section 9, on page 11.
Replacement bedding. Please tell us why this is
needed in Section 9, on page 11.
Extra water costs.
Basic garden maintenance.
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Extra heating costs.
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Special clothing or footwear. Please tell us why this
is needed in Section 9, on page 11.
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Basic cleaning or domestic help.
Disability equipment (costs of purchase,
maintenance and repair). Please tell us how often
you have to pay for each of these in Section 9, on
page 11.
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Other expenses please list below:

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Extra travel costs. Please tell us about these in
Section 9, on page 11.
Continue in Section 9, on page 11 or on a separate sheet if required.
If you have claimed for transport costs do you have a Motability vehicle?
–9–
Yes
No
Section 8 Declaration by All Service Users
(i)
I understand that the services I receive are subject to a charge which is reviewed annually.
(ii)
I agree to pay any charges that I have been assessed to pay.
(iii) The information I have given is true and complete and I have no other financial resources that I have
not declared.
(iv) I will notify the relevant Financial Assessment Team of any changes to the information I have given.
(v)
I understand that Suffolk County Council reserves the right to reassess and backdate charges should any
undeclared assets be discovered.
(vi) I understand that I may be asked to provide evidence of my income, savings and capital assets and any
allowable expenses.
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(vii) I agree to Suffolk County Council verifying any details I have given in this document, including contacting
the Department for Work and Pensions.
Any personal information you provide us with will be processed in accordance with the Data Protection
Act 1998.
Signature of Service User
Date
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OR
Signature of Service
User’s Representative
Date
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Please tick below to indicate which documents you are enclosing and whether they are original documents
or copies.
Please note we will not return copy documents unless you ask us to.
Document
Section 1B
Formal confirmation that financial responsibility is held by a
third party.
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Documents showing any benefits and other income
you receive.
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Section 3
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Reference
on form
Section 4
Financial documents, including any documents relating
to Trusts and Equity Release, to support all entries in
this Section.
Section 6B
Sheltered or Very Sheltered Housing rent and additional
charges statement.
Section 7A
Disability Related Expenses supporting evidence.
– 10 –
Original
Documents
Enclosed
Copy
Documents
Enclosed
Section 9 Any other information
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Please use this space to tell us about anything else you feel we need to know or for any other information
from elsewhere on the form where there is not enough space.
If this form has been left with you for completion please return it now with any supporting
documents to:
For residential/nursing care
For all other services
Financial Assessment & Charging Team
Adult & Community Services
Clapham House
Clapham Road
LOWESTOFT NR32 1QX
Tel: 01502 674525
Financial Assessment & Charging Team
Adult & Community Services
Endeavour House
8 Russell Road
IPSWICH IP1 2BX
Tel: 01473 264544
– 11 –
Section 10
For Office Use ONLY
Declaration by Suffolk County Council staff
If the service user is unable to sign the Declaration at Section 8, and the service user’s representative does
not act under a Power of Attorney or is a Court Appointed Deputy, please confirm your discussion by
signing below.
Name
Signature
Date
Job title
Contact No.
Service Details – Care Assessor to complete before issue
to customer
or
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Section 11
Customer’s CareFirst No.
Care Assessor’s Name
Section 12
Date
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Care Assessor’s Signature
Financial Assessment Team only –
Financial Assessment Details
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Date assessed:
Letter code:
Weekly customer charge:
£
Customer notification letter date:
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Charges due date:
Surname
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Assessed by:
Additional Information
Actions
Initials
Countersigned:
Date:
Once completed this form is classified as OFFICIAL – SENSITIVE [PERSONAL]
Forename
Customer documents
photocopied & returned: