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Change of Address Form Help with your Rent and Council Tax - PDF
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1 Change of Address Form Help with your Rent and Council Tax Please do not write in this box. It is for office use only. Office receipt date stamp of issue: Please read all of the notes shown on this page and in parts 8 and 9 of this form before you answer the questions. Use this form to tell us about your change of address and if you want to make a claim for Housing Benefit and an application for Council Tax reduction. Do not use pencil. If you make a mistake, just cross it out and put the right answer next to it. Do not use correction fluid. Part 1 About you Title (Mr, Mrs, Ms, Miss, Mx, Other) of birth First name Last name Daytime phone number address Part 2 About your old address Your old address and postcode (include your room or flat number) Sign and date the form before sending it back with all the evidence we need. Please return this form immediately. If you cannot provide all the evidence we need, do not delay in returning the form; tell us what evidence you will be sending and remember to send it to us within 21 days if you are applying for Council Tax Reduction or one calendar month if claiming Housing Benefit. Your Housing Benefit or Council Tax Reduction reference number Council Tax account number National Insurance number About your new address Your new address and postcode (include your room or flat number) you moved out, or date you will move out, of your old address Until what date are you being charged rent at the above address? (if this is different from the date above) you moved in, or date you will move in, to your new address from which you need to pay rent at the new address (if this is different from the date above) Part 3 About your new tenancy Is your new tenancy in joint names? If Yes, write the names of the joint tenants below. Are you: a private tenant? a boarder? a housing-association tenant? a council tenant? a hostel tenant? an owner-occupier? other? If Other, give details below.
2 Council tenants go to Part 6, owner-occupiers go to Part 8 and continue to fill in the form. If you are a private tenant, housing-association tenant or hostel tenant, please continue to fill in part 4 onwards. Part 4 New rent details From what date did you start paying rent at this address? How much rent do you pay? How often do you pay your rent? Every week Every two weeks Every month Every four weeks If you owe rent for this address, please tell us how much. Are there weeks when you do not have to pay rent? If Yes, how many rent-free weeks do you have in a year? What type of tenancy do you have? (For example, shorthold or assured shorthold.) How long is the tenancy? From: To: Does anyone else share the rent with you and your partner? Yes No If Yes, give their names and their relationship to you or your partner. Name Relationship How much rent do they pay? How often do they pay rent? every Who do you pay rent to? Is this? (please tick) a landlord an agent a trustee Does your landlord live at the same address as you? Are you or any member of your household related to your landlord, your landlord s agent or the trustee who you pay rent to? ( Related includes related through marriage, even if the marriage has ended.) If you answered Yes to the question above, please tell us their names and their relationship to the landlord, agent or trustee. Name Relationship Part 5 New rent charges Does your rent include the following? If Yes, give the amount and how often. Includes Tick box Yes or No Amount How often? Meals every For which meals? Breakfast Lunch Dinner (please tick all that apply) Water charges every Heating every Lighting every Hot water every Fuel for cooking every Laundry every Cleaning rooms every or windows
3 Part 5 New rent charges (continued) Does your rent include the following? If Yes, give the amount and how often. Includes Tick box Yes or No Amount How often? Gardening every Garage or parking space every Do you have to rent a garage as part of your tenancy agreement? Yes No Are there any other services included in your rent? If Yes, please tell us below what services are included. every Does your rent include money for personal care and support? Part 6 New property details How is your property let? (please tick one box) Furnished Partly furnished Unfurnished What sort of property do you rent? (please tick one box) Bedsit Studio flat Double bedsit Flat in house Flat in block Flat over shop Detached house Semi-detached house Terraced house Bungalow Maisonette If other please give details below Hostel with board and lodgings Residential care home Room or rooms Hostel Hotel Other accomodation If your accommodation is a room or rooms, bedsit, double bedsit or studio flat, where is it in the building? Please tick one box here. Please tick one box here. Front Left Middle Middle Back Right Does your home have central heating? Who is responsible for decorating your home? You Your landlord Will everyone who lived with you at the old address be moving with you to the new address? If No, please tell us who will not be moving with you. If someone else is moving in with you at your new address who did not live with you before, please give us their details.
4 Part 6 New property details (continued) Do you or anyone in your household use only part of the building you live in? How many floors are there in the whole building? What floor or floors do you live on? Basement Ground First Second Other Fill in the table below to tell us how many rooms there are in your property: Living rooms Bedsits or rooms Bedrooms Bathrooms or shower rooms Toilets Kitchens Other rooms in the whole property just for you that you share If you have put a number in Other rooms, please list these rooms. Do you use your home for business? Part 7 New payment details If you are entitled to Council Tax Reduction or Alternative Maximum Council Tax Reduction, we will pay this into your Council Tax account. If you are a council tenant, we will pay any Housing Benefit you are awarded into your rent account. If you are a private tenant renting from a housing association, a charity or a hostel, normally you can choose how your benefit is paid. Payments can be made either into your own bank or building society account or to your landlord. For all other private tenants, your benefit will be paid direct into your account. If you have difficulty managing your money, paying your rent, or you have secured and retained your tenancy by agreeing to pay your landlord direct, it may be possible to pay your landlord. Please provide any information and evidence so we can make a decision. Do you want your Housing Benefit paid direct into your bank or building society account? If Yes, please fill in the details below. Name of bank or building society Bank or building society s address Name of the account holder Account number Sort code Building society roll number - - Do you want your Housing Benefit paid direct to your landlord or agent? If Yes, please ask your landlord to fill in section B on page 8. We cannot pay Housing Benefit into the Post Office Card Account. If you do not have a bank account, and would like information about opening one, please visit the Financial Services Authority website at Alternatively, you can request one of our Basic Bank Account booklets by ticking here
5 Part 8 Sending us proof of your change of address We need proof about your new rent charge or the rent charge for your new address. We may not be able to work out your benefit entitlement without this proof. If you cannot send us proof with this form, you can send it later. We may stop payments while we wait for your proof. We will write to you about this. If you do not send us the information, we may end your entitlement to Housing Benefit or Council Tax Reduction. We will accept the following proof: A tenancy agreement A filled-in and signed landlord rent declaration form (see page 7 of this form) A letter from your landlord Part 9 Change in circumstances You must tell us about any changes in writing, a phone call is not enough. Do not rely on anyone else to tell us. If you do not tell us about any changes, or you delay telling us, you may lose money you are entitled to or you may be awarded too much and have to pay it back. It is an offence not to tell Haringey Revenues and Benefits Service about any changes that may affect your entitlement. Haringey Revenues and Benefits may take action against you if you do not tell us. Our contact details are on page 6. Have you had any other changes in circumstances which may affect your entitlement to Housing Benefit or Council Tax Reduction (or both)? If Yes, please tick the box below to show what change or changes you are reporting and the date they apply from. A change to my income A change to my household A change to my household income from from from Another change from Please give details of the change or changes. Please continue on a separate sheet if you need to, and attach it to this form. Please sign and date all the sheets you use (if you attach extra sheets, please include your reference number on each of them). Part 10 Declaration Please read the declaration below before you sign and date it. Even if someone else has filled it in for you, you must sign this declaration if you can. I understand that: you will use the information I have provided to assess my claim for Housing Benefit or application for Council Tax Reduction or both; you will use the information I have provided to assess my liability for Council Tax; you may use any information I have provided in connection with this and any other claim for state benefits; you may check some of the information with other sources within the council, rent offices and other councils; you may give information to other government organisations, if the law allows this; and if you pay me too much benefit because I have failed to give you correct or complete information, I will have to pay this money back. If I do not, you will take court action against me to recover the money. I confirm that the information I have given is true and complete. Please work out my entitlement to Housing Benefit or Council Tax Reduction. Signature Your partner s signature Filling in the form for someone else Why are you filling in the form for the person claiming Housing Benefit or applying for Council Tax Reduction. Your name and address Signature Relationship to the person claiming Housing Benefit or applying for Council Tax Reduction.
6 How to contact us for help and advice How to contact us for help and advice Just click on: Telephone us on: Write to us at: Revenues, Benefits and Customer Services P.O. Box Wood Green London N22 7WJ Customer Service Centres South Tottenham Customer Service Centre Apex House 820 Seven Sisters Road N15 5PQ Wood Green Customer Service Centre 48 Station Road Wood Green N22 7TY Write to us Benefits Service London Borough of Haringey PO BOX Wood Green N22 7WJ Haringey Council Customer Services Call Centre For guidance with the completion of the form please visit one of our Customer Service Centres Shqip Polski Français Soomaali Türkçe Kurdî Kurmancî This is printed on recycled paper. When you have finished with it, please recycle. Published by Haringey Council s Communications Unit /2013
7 Part 11 Landlord s/agent s tenancy declaration (only fill in this section if you don t have a tenancy agreement. If you are handing in a tenancy agreement with this form, go to part 12) If you do not have a tenancy agreement and you want to use this form as proof of the rent you pay to your landlord, please fill in part A below. Then tear this out and ask your landlord or agent to fill in part B and sign it, then send it back to us. Do not delay in returning your form. If you are a private tenant renting from a housing association, a charity or a hostel, normally you can choose how your benefit is paid, either into your own bank or building society account or to your landlord. If you want us to pay your landlord direct, you must fill in page 8. For all other private tenants, your benefit will be paid direct into your account. If you have difficulty managing your money or paying your rent, it may be possible to pay your landlord. Please provide any information and evidence so we can make a decision. Part A You must fill this in Your name and phone number Your home address Part B Your landlord or agent (if there is one) must fill this in Landlord s name Landlord s address Landlord s phone no address When did the tenancy start? What type of tenancy is it? (For example, shorthold.) Is it a joint tenancy? If Yes, name the joint tenants If Yes, name the joint tenants. How many rooms are there in the property? Which rooms are shared with Agent s name Agent s address Agent s phone no address How much is the rent? every What date is the rent paid up to? other tenants? Does the rent include the following? If Yes, give the amount and how often this charge is due to be paid. Includes Tick box Yes or No Amount and how often this charge is due to be paid? Water rates every Heating every Lighting every Hot water every Cooking facilities every Meals every Council tax every Other (give details) every Has your tenant missed any rent payments? If no rent has been paid yet, write none paid in the box below. If Yes, how much do they owe? For how many weeks or months? How many are used only by the tenant s household? Landlord s/agent s declaration. Please read the declaration before you sign this form. As far as I know, the information I have given on this form is accurate. You can check the information on this form. I will tell Haringey Revenues and Benefits straight away if any of the information on this form changes. I know that you may prosecute me if I make a false statement. I understand that you cannot give me details of my tenant s claim without their permission. Signature
8 Part 12 Paying benefit direct to your landlord or their agent If you want us to pay your Housing Benefit direct to your landlord or agent, please fill in part A below. Tear this page out and ask your landlord or agent to fill in part B and sign it, then send it back to us. If you are a private tenant who does not rent from a housing association, charity or hostel, we will normally pay benefit directly to you. If you want your benefit paid directly to your landlord, you must give good reason as to why we should not pay you. Part A You must fill this in Your name Your address Your phone number Housing Benefit reference number (if you know it) Part B Your landlord or agent (if there is one) must fill this in Landlord s name Address Phone number Agent s name (if there s one) Address Phone number I am the landlord or agent (please tick one box) named above or I have permission to sign on their behalf. I would like the Housing Benefit for the tenant to be paid direct to the following bank account. Name of bank or building society Bank or building society s address Name of the account holder Account number Sort code Building society roll number - - Landlord s/agent s declaration Please read the declaration before you sign this form. I am the owner or the agent of the property the tenant is living in. I agree to accept Housing Benefit payments for the tenant named above. I understand that I must tell Haringey Revenues and Benefits if I know about any change in circumstances that may affect this tenant s benefit. I understand that if I am overpaid benefit for this tenant, it can be recovered from me as allowed by the Social Security Administration Act 1992 and the Housing Benefit Regulations I have read and understood this declaration. Landlord s/agent s signature