Claim Form for Housing Benefit
and Council Tax Support
Name:
Address:
For office use:
Claim reference:
Date issued:
Date received:
Full postcode:
You can check if you may be entitled to benefit using our online benefits calculator at
www.Iichfielddc.gov.uk/benefits
Important – please read these help notes carefully before you fill in the form.
Please make sure that your claim address is stated on the front of this form.
If your capital is more than £16,000, you will not be entitled to any Housing Benefit, except
if you receive Pension Credit Guarantee. If your capital is more than £6,000, you will not
be entitled to Council Tax Support, except if you are receiving Income Support, income
based Job Seeker’s Allowance or income related Employment Support Allowance or if
you are a pensioner.
If you have got this form from anyone other than the council, for example, your
landlord, you must contact us immediately on 01543 308900 to register the date of
your claim.
Please answer all the questions completing every box. If you do not, we may return your
claim form.
When completing this form, please write your answers in the white boxes only. When the
questions have ‘Yes’ and ‘No’ boxes for your answer, clearly tick (✓) one box only.
We may need proof of the information you give us. We will tell you what proof we need at the
end of each section. All the documents you give us must be original documents. Please
supply all the proof with this form. Do not post important or valuable documents, please
bring them into the office. We will copy all of the documents and give them back to you. We
cannot accept your own photocopies.
You must get your claim and all of the proof we need back to the council as soon as
possible (no later than one calendar month if you have already registered your claim), if
you do not you may lose benefit/support.
When we receive your application form, we will send you a receipt. If you do not get a
receipt within five working days, contact us immediately.
1
If your circumstances change you must tell the Benefits Section straight away. If you do
not tell us promptly, you will be breaking the law and the council may take action against
you.
Examples of changes in circumstances you must report to Lichfield District Council:
you or your partner’s Income Support or Jobseeker’s Allowance stops
you or your partner start work
you or your partner have any changes to your income
someone joins or leaves your household
anyone in your household has a change in income
child benefit changes
your rent changes
you move, or any absence from home likely to last more than 13 weeks
your capital changes
your child care costs change
your tax credits change.
If you are in paid employment and your earnings vary from one pay day to the next, we will try
to use a figure that most represents what your future earnings will be. This will mean taking
an average of your pay.
You need to keep the council informed of any fluctuations in your earnings. It would be helpful
if you could send your pay slips into the office every three months to ensure that the earnings
figure included in your assessment is correct. This will help avoid an overpayment and will
ensure you receive the right amount of benefit.
If you get Pension Credit, you will usually report changes to the Pensions Service but there
are still some changes you must tell us about in writing – these are listed on the receipt.
Declaration. I have read and understand the help notes. I understand I must report any
changes in circumstances promptly.
Signed .......................................................................... Date .......................................................
Partner’s signature .......................................................
1
Type of claim
If you are of working age - go to section 2.
If you are a pensioner, you may qualify for Second Adult Rebate. This might help you if you are not
entitled to Council Tax Support in your own right because of your income. If there is another adult in
the household (other than your partner) and they are on a low income, we may be able to work out
your benefit using their gross income.
I want to claim Second Adult Rebate only
Yes
No
If ‘Yes’, please put your full name, address, date of birth and National Insurance Number on page 3.
You will also need to fill in section 5, starting on page 6.
Proof
We need to see proof of the second adult’s income. This must show their present address, the type
of income and how much they receive.
We need to see proof of your identity.
2
2
About you and your partner
Do you have a partner?
Yes
No
This is someone you are married to or live with as a couple, including civil partnerships, same sex
couples and partners that work away from home.
If ‘Yes’, you must also give us details about your partner where we ask for them on the form.
You
Title
Mr
Mrs
Your partner
Miss
Ms
Mr
Mrs
Miss
Ms
Surname
First names
Date of birth
National Insurance
Number
Marital status
Phone number
Email address
What date did you
move into this address?
Tell us the names of
everyone who owns this
property
If you have moved
within the last 10 years
please tell us your
previous address
Postcode
Postcode
Did you own your last home?
Yes
No
Yes
No
Did you claim Housing Benefit
or Council Tax Support at your
last address?
Yes
No
Yes
No
Proof
We need to see proof of your identity and proof of your National Insurance Number. If you have a
partner, we also need to see proof of their National Insurance Number. This proof must be at least
two official documents that confirm who you and your partner are.
3
2
About you and your partner – continued
Are you a care leaver under
the age of 22?
Yes
No
Yes
No
Are you or your partner
registered blind?
Yes
No
Yes
No
Yes
No
Yes
No
Is anyone getting Carer’s
Allowance for looking
after you or your partner?
If ‘Yes’, give their full
name and address
What date did you come
to live in the UK?
/
/
If ‘Yes’, what is your nationality?
Have you come to live in the UK
under a sponsorship undertaking?
Yes
No
Have you applied for asylum?
Yes
No
3
About your joint tenant
Are you a joint tenant?
Yes
No
If ‘Yes’, please give details below.
If ‘No’, please go to section 4.
Please give the names of all joint tenants
1st person
2nd person
3rd person
4th person
Surname
First name
Male or female
Relationship to you
If any of the above are partners,
please tell us who they are
Do they live in the property?
Yes
No
Yes
4
No
Yes
No
Yes
No
4
About any children
If 'Yes', please give details below. Only give details of
children you receive Child Benefit for. If you have more
than 4 children please continue on a separate page.
Yes
Do you have any children
who live with you?
If ‘No’, please go to section 5.
No
1st child
2nd child
3rd child
4th child
Surname
First name
Relationship to you (for
example son or daughter)
/
Date of birth
Are they registered blind?
/
/
/
/
/
/
/
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Are they in full time education? Yes
No
Yes
No
Yes
No
Yes
No
Are they getting Disability
Living Allowance or Personal
Independance Payments?
If ‘Yes’ and they will be
leaving in the next 12 months
please tell us when
Do you pay a registered child minder/ Yes
after school club or day nursery to
No
look after any of your children?
If ‘Yes’, how much do you pay?
If ‘Yes’, please give details below.
If ‘No’, please go to ‘Proof’ below.
How often do you pay this?
£
Please give the names of the
children you pay this for
Do you receive a grant towards
your childcare costs?
No
Yes
Proof
We need to see proof that you are getting Child Benefit, Disability Living Allowance or Personal
Independance Payments (if applicable). You must provide birth certificates for children under age of 5.
If you pay for childcare, please send a letter from the child minder or nursery confirming the amount
you pay. This should give their registration number. If you receive a grant, we need to see proof of the
amount you get.
5
5
About any other people living in your home
Does anyone else live in your home?
If ‘Yes’, please give details below. If there are more
than 4 people please continue on a separate sheet.
Yes
No
If ‘No’, please go to section 6.
You must tell us about everyone else who lives in y our home.
1st person
2nd person
3rd person
4th person
Surname
First name
National Insurance Number
Relationship to you (for
example son, daughter, tenant)
Date of birth
/
/
/
/
/
/
/
/
If any of the above are partners,
please tell us who they are
If any of these people are boarders or tenants please go to section 14 and tell us about the
amount they pay you. If they are not boarders or tenants, please complete the rest of this
section.
Do they work?
Yes
No
Yes
No
Yes
No
Yes
No
Number of hours worked
each week
Weekly pay before any
stoppages
£
£
£
£
Do they get Income Support,
Jobseeker’s Allowance or
Yes
Employment Support Allowance?
No
Yes
No
Yes
No
Yes
No
Do they get Pension Credit?
Yes
No
Yes
No
Yes
No
Yes
No
Are they a student?
Yes
No
Yes
No
Yes
No
Yes
No
If ‘Yes’, we need to see the enrolment certificate.
Are they an apprentice?
Yes
No
Yes
No
Yes
No
Yes
No
Are they a carer?
Yes
No
Yes
No
Yes
No
Yes
No
6
5
About any other people living in your home – continued
1st person
2nd person
3rd person
4th person
Are they severely
mentally impaired?
Yes
No
Yes
No
Yes
No
Yes
No
Do they receive any
other income?
Yes
No
Yes
No
Yes
No
Yes
No
If ‘Yes’, what is it?
How much do they
receive each week?
£
£
£
£
Proof
We need to see proof of the income of everyone you have listed in section 5, except tenants and
boarders. If they are working, this proof should be their last five payslips if they are paid weekly, their
last two payslips if they are paid monthly, or their last three payslips if they are paid fortnightly.
If they are getting a benefit, we need to see a recent letter from the Department for Work and
Pensions, the Job Centre or the Pensions Service.
6
Students
By ‘student’ we mean someone who is in further or higher education.
Are you or your partner (if you have one) students?
If ‘Yes’, please give details below.
Yes
You
No
Your partner
Is your course full time (usually more than
16 hours) or part-time?
Value of any grant or loan
£
£
Value of any money paid by parents
or deed of covenant
£
£
Date academic year starts
/
/
/
/
Date academic year ends
/
/
/
/
Please give the name and type of course
you are following
Proof
We need to see the original grant or loan award notice and evidence of the hours of study.
7
7
About your work
Do you or your partner work?
Please include voluntary, temporary
or unpaid work
Yes
/
If ‘No’, what date did you last work
No
Yes
/
No
/
/
/
/
If ‘Yes’, give details below. If you are self-employed go to section 8.
/
What date did you start?
/
Job title (including company directors)
Name and address of employer
Employer’s phone number
Number of hours you work each week
Your payroll number
Average pay before tax
How often are you paid? (for example
weekly, 4 weekly, calendar monthly)
How are you paid? (for example
cash, cheque, straight into bank)
Do you get any bonuses, overtime,
commission or tips?
Yes
No
Yes
No
If ‘Yes’, how often do you get them?
How much do you get?
£
£
/
When is your next pay rise due?
Do you or your partner have more
than one job?
Yes
/
No
/
Yes
/
No
If ‘Yes’, please give details on a separate sheet.
If you pay into a private pension scheme and the payment does not come out of your wages,
please provide evidence of your payments.
Proof
We need to see your last five payslips, if you are paid weekly, your last three if you are paid
fortnightly, or your last two if you are paid monthly. The payslips must show your employer’s name,
the number of hours worked and the period covered, gross pay for the year to date, gross pay for the
pay period and any deductions for income tax, national insurance and pension contributions.
If you do not get payslips or have handwritten payslips, please contact us for an employment
certificate.
8
8
About your self-employment
You
Are you or your partner self-employed
Your partner
Yes
No
Yes
No
Yes
No
Yes
No
Do you run your business from your home?
Yes
No
Yes
No
Do you or your partner get a
Business Start-up Allowance?
Yes
No
Yes
No
Do you have a Business Account?
Yes
No
Yes
No
If ‘Yes’, give details below.
When did your business start?
What is the nature of your selfemployed trade or business?
Name and address of the business
How many hours do you work?
What do you estimate your
weekly net profit to be?
Are you a partner in the business?
If ‘Yes’, please give the names of the
other business partner or partners
If ‘Yes’, when did it start?
Do you also work for someone else?
/
Yes
/
No
/
Yes
/
No
If ‘Yes’, what other work do you do?
If you pay into a private pension scheme please provide evidence of your payments.
Proof
We need you to complete a self-employed questionnaire form, which we will provide on receipt of
your claim.
We need to see your latest audited accounts. If you do not have any accounts, send us a summary of
your book keeping records for the last twelve months with your receipts.
If you or your partner are company directors, please tell us in section 14 “Other Information” on
page 17.
9
9
About other income (but not your earnings)
Tell us if you receive any of the income listed in this section.
You must answer every question. If you do not, we may need to return the form to you.
Your partner
You
How much
How often
How much
Income Support
Yes
No
Yes
No
Jobseeker’s Allowance
Yes
No
Yes
No
Employment Support
Allowance
Yes
No
Yes
No
Employment
Training Allowance
Yes
No
Yes
No
Universal Credit
Yes
No
Yes
No
Maintenance payments you receive
Yes
(excluding child maintenance)
No
Yes
No
Child Benefit
Yes
No
Yes
No
Child Tax Credit
Yes
No
Yes
No
Working Tax Credit
Yes
No
Yes
No
State Retirement Pension
Yes
No
Yes
No
Bereavement Benefit
Yes
No
Yes
No
Pension Credit Guarantee
Yes
No
Yes
No
Savings Credit
Yes
No
Yes
No
Private or works pension
(after tax)
Yes
No
Yes
No
Annuities/other pension
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
War Disablement Pension
Yes
No
Yes
No
Attendance Allowance
Yes
No
Yes
No
Personal Independence Payments Yes
Daily Living Component
No
Yes
No
Personal Independence Payment Yes
Mobility Component
No
Yes
No
No
Yes
No
Widow’s Allowance
or Pension
War Widow’s or
Dependant’s Pension
Disability Living Allowance
Mobility component
Yes
10
How often
9
About other income (but not your earnings) – continued
You
How much
Your partner
How often
How much
Disability Living Allowance
Care component
Yes
No
Yes
No
Statutory Sick Pay
Yes
No
Yes
No
Incapacity Benefit
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Industrial Death Benefit
Yes
No
Yes
No
Reduced Earnings Allowance
Yes
No
Yes
No
Maternity Allowance/Pay
(paid by employer)
Yes
No
Yes
No
Statutory Adoption Pay
Yes
No
Yes
No
Statutory Paternity Pay
Yes
No
Yes
No
Fostering Allowance
Yes
No
Yes
No
Adoption or
Custodianship Allowance
Yes
No
Yes
No
Payment from boarders
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Carer’s Allowance
Yes
No
Yes
No
Any other income
Yes
No
Yes
No
Severe
Disablement Allowance
Industrial Injuries
Disablement Benefit
Rent received from letting
or sub-letting a property
Payments from a mortgage
protection policy
How often
Have you applied for Carer’s
Allowance but are not entitled
because you are getting another
Social Security benefit?
Yes
No
Yes
No
Have you applied for any benefits
and are waiting to hear?
Yes
No
Yes
No
If ‘Yes’, what have you applied for?
Proof
We need to see proof of all the income that you get. This must show your present address, the type
of income and how much you receive.
11
10
About savings and investments – this includes current accounts
If you and your partner have a joint account, please enter the amount under the name that is first on
the account. If either of you have a joint account with someone else, please give us details in section
14 ‘Other information’ on page 17.
You
Your partner
Bank accounts
Do you have any bank accounts?
Yes
No
Yes
No
If ‘Yes’, how many?
Account Number
Amount
Account Number
Amount
Please say what type of account
each one is and how much
money is in it
Continue on a separate
sheet if you need to.
Building society accounts
Do you have any building society accounts? Yes
No
Yes
No
If ‘Yes’, how many?
Please say what type of account
each one is and how much
money is in it
Account Number
Amount
Account Number
Amount
Continue on a separate
sheet if you need to.
Post Office accounts
Do you have any Post Office accounts?
Yes
No
Yes
No
If ‘Yes’, how many?
Account Number
Amount
Account Number
Amount
Please say what type of account
each one is and how much
money is in it
Continue on a separate
sheet if you need to.
Other
Do you have any cash savings?
Yes
No
Yes
Amount
If ‘Yes’, how much?
£
Amount
£
12
No
10
About savings and investments – continued
You
Do you have any Premium Bonds?
Yes
No
How many
If ‘Yes’, please give details.
Do you have any National Savings?
Value
Yes
Yes
If ‘Yes’, please give details.
No
How many
£
Issue Number
Do you have any stocks,
shares or unit trusts?
Your partner
Value
£
No
Purchase Value
Yes
Issue Number
£
No
Purchase Value
£
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If you have shares, please list
the companies and the number of
shares for each one. Use a separate
sheet of paper if you need to.
Do you or your partner own, or jointly
own, any other land or properties either
in the UK or abroad, including timeshare?
Please give the address of any other
land or properties that you or your
partner own. We may write to you
for more information.
Have you or your partner received
any compensation payments?
If ‘Yes’, please give details
Proof
We need to see proof of all capital, savings, investments and current accounts held by you and your
partner where your capital is greater than £6,000 for working age claims and £10,000 for pensioner age claims.
This must show who the money is invested with, the type of account and the amount invested.
In certain circumstances we may ask you for proof of your capital where you have less than this.
Remember if you are claiming Council Tax Support only you will not be entitled to support if you have more
than £6,000.
We cannot accept a print out from the bank or building society showing just the balance of your
account. Your proof must show the last three months’ transactions.
13
11
About your tenancy
If you are claiming Council Tax Support only – go to section 14.
What date did your agreement to pay rent start?
/
How much does your landlord charge you?
Weekly
Fortnightly
Calendar
monthly
/
£
4 weekly
Other
What is the full name and address
of your landlord/agent?
Are you, your partner, or your child related
to your landlord or your landlord’s partner?
Yes
No
If ‘Yes’, please say how you are related.
Please tell us about
your accommodation
Bedsits
Bedrooms
Living
rooms
Kitchens
Bathrooms
Other rooms
(please state)
Total
Total number of rooms in
the whole property
Number used only by you
and your family
Number you share with
people other than your family
Is a garage included as part of your tenancy agreement?
Yes
No
If ‘Yes’, did you have any option about renting the garage?
Yes
No
Does your rent include any of the following? If ‘Yes’, please give the amount.
Water rates
Yes
No
£
Heating
Yes
No
£
Lighting
Yes
No
£
General counselling and support
Yes
No
£
Emergency alarm
Yes
No
£
14
11
About your tenancy – continued
Does your rent include any of these meals?
Breakfast
Yes
No
Lunch
Yes
No
Evening meal
Yes
No
No
Don’t know
Has your rent been registered by the Rent
Officer or the Rent Assessment Committee?
Yes
Proof
If this is your first claim we need to see:
·
Your tenancy agreement. If you do not have one, please contact us for a Tenancy Details form.
·
We also need to see proof of rent payments or arrears, such as receipts, rent statements,
bank statements or your rent book. If you do not have proof of rent payments, please ask your
landlord to confirm in writing:
– that you have been paying the shortfall between the Housing Benefit and the rent charged
(if there is any)
– the amount of any arrears
– the amount of any credit
12
Sharing information with your landlord
Sharing information with your landlord could help us deal with your claim more quickly. If you give us
permission, we will be able to tell your landlord about any information we are waiting for. If we are
paying Housing Benefit to your landlord on your behalf, we will also send them a decision notice.
We would only give your landlord this information if they request it. However we will not give your
landlord any information about your personal, household or financial circumstances.
You can withdraw your permission at any time. It will not affect your claim if you do not give us
permission to discuss your claim with your landlord.
I give the council my permission to share information about the progress of my Housing
Benefit claim with my landlord or their representative.
Signature
Date
15
13
About paying your benefit
If you are a private tenant affected by Local Housing Allowance, payments will be made direct to
you, unless there is a reason why you cannot receive your payment.
Please tell us here why we should pay your landlord.
If you are a Housing Association tenant you can ask us to pay your Housing Benefit to your landlord.
Do you want us to pay your Housing Benefit to
your landlord, the agent or to you?
You
landlord
agent
NB. If we make payments directly to you, we will pay you every two weeks. If we send payments to
your landlord or agent we have to send them every four weeks. We cannot pay benefit in advance;
payments will be sent at the end of the period they are for.
Your benefit will be paid straight into the bank/building society account of your choice. We cannot pay
benefit into a post office account. Please tell us about the account you want your benefit paid into.
Name of bank/building society account
Branch
Sort Code
Account number
Roll number (for building society)
Account name
If you want your benefit paid into your landlord or agent’s bank/building society account, please tell us
their account details.
16
14
Other information
If you would like to give us any other information which could help in working out your benefit, please
tell us here.
15
Backdating
Housing Benefit and Council Tax Support usually starts from the Monday after we receive your claim
form. We may be able to pay benefit before the date of your claim if there is a good reason why you
did not claim earlier. Please see www.lichfieldddc.gov.uk/benefits for ‘How far can you backdate my
claim?’
Do you want to claim backdated benefit?
Yes
If ‘Yes’, what date do you want the claim to go back to?
Please explain why you did not claim earlier.
17
No
/
/
16
Your declaration
Please read this declaration carefully before you sign and date it. I understand the following:
·
·
·
If I give information that is incorrect or incomplete, you may take action against me.
You will use the information I have given to process my claim for Housing Benefit or Council Tax
Support, or both. You may check some of the information with other sources in the council, rent
offices, and other councils.
You may use any information I have given for this and for any other claim for Social Security
benefits that I have made, or may make. You may give some information to other government
organisations, if the law allows this.
I know I must let the Benefits Section know promptly about any changes in my circumstances,
which might affect my claim.
I declare the information I have given on this form is correct and complete.
Signature of person claiming
Partner’s signature
Date
/
/
If all or part of this form is filled in by someone other than the person claiming
Please tell us why you are
filling in this form for
someone else.
Name of the person who filled in the form
Signature of the person
Relationship to the person claiming, including
appointee or power of attorney.
If you are the appointee or have power of attorney, you should sign the form as if you are the
claimant.
Confidentiality statement
The information collected on this form and the supporting evidence will be used by Lichfield District
Council to work out your Housing Benefit and Council Tax Support.
This authority is under a duty to protect the public funds it administers, and to this end may use the
information you have provided on this form for the prevention and detection of fraud and crime. We
may also share this information with bodies responsible for auditing or administering public funds
and for the purposes of conducting datamatching exercises to prevent and/or detect potential fraud
and crime or as necessary to comply with any other legal obligation.
We will not give information about you to anyone unless the law allows us to.
Lichfield District Council is the Data Controller under the Data Protection Act. If you want to know
more about the information we have about you, or the way we use your information, you can ask for
this in writing. Please send your letter to the Housing Benefit Section.
18
17
Your receipt
Received by
Date
/
/
Please keep this receipt as it contains important information regarding your claim.
What happens next? Your claim and proof will be checked. If it is complete, we will
process your claim and you will get a decision notice. You should check this notice
carefully and contact us immediately if anything goes wrong.
If your circumstances change you must tell the Benefits Section straight away. If you
do not do this promptly, you will be breaking the law and the Department for Work
and Pensions may take action against you.
Examples of changes in circumstances are given on the claim form and also on the back
of the decision notice. If you are not sure, please contact us.
If you are in paid employment and your earnings vary from one pay day to the next, we
use a figure that most represents what your future earnings will be, by taking an average
of your pay.
You need to keep the council informed of any fluctuations in your earnings. It would be
helpful if you could send your pay slips into the office every three months to ensure that
the earnings figure included in your assessment is correct. This will avoid an overpayment
and will ensure you receive the right amount of benefit.
If you are receiving Pension Credit you will usually report your changes to the Pension
Service but you must still tell us about the following changes in writing:
• Changes to your tenancy or the amount of rent payable
• Changes relating to non-dependants
• If you are away from home for any period that is likely to be 13 weeks
• If your Pension Credit stops
If you only receive Savings Credit you must also report
• Changes in household members
• If your capital goes above £16,000
• Changes to the income of a partner not included in the pension credit claim.
Discretionary Housing Payments
Discretionary Housing Benefits may be awarded where the council considers that a claimant
requires further financial assistance towards housing costs as a temporary measure.
Awards will be made in accordance with Lichfield District Council’s Discretionary Housing
Payments Policy. The policy can be found at www.lichfielddc.gov.uk/dhp
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You can find out more information about Housing and Council Tax Support by visiting our
website at www.lichfielddc.gov.uk/benefits
You can contact us by
• Email to [email protected]
• Telephone 01543 308900 / Minicom only 01543 308078
• Post to
Lichfield District Council
District Council House
Frog Lane
Lichfield
Staffordshire WS13 6YX
• In person at the above address.
The Department for Work and Pensions can be contacted at
Social Security Office
15 Stafford Street
Hanley
Stoke on Trent ST1 1RE
Telephone: 0845 608 8673
Textphone: 01782 224559
The Pension Service can be contacted on
Freephone: 0800 99 1234
Textphone: 0800 169 0133
Your local Citizens Advice Bureau is at:
Or if you live in the Burntwood area:
29 Levetts Field
Lichfield
Staffordshire WS13 6HY
Telephone: 01543 252730
Wade House
7 Cannock Road
Burntwood
Staffordshire WS7 8JS
Telephone: 0844 856 3400
Help us to prevent benefit fraud
Benefit fraud is a crime. Why should you pay for it?
If you have any information relating to a known or suspected benefit fraud please call:
Freephone 0800 783 1030
All calls and information will be treated in confidence.
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