Continuing Healthcare and additional payments……………………………… 10 Top-up financial questionnaire …………………………………………………. 12 Top-up declaration/ agreement ………………………………………………… 17
Your Income How Often? (Please Circle) Company & Reference/ Account Number Amount? Documents seen by Officer State Retirement Pension* Week/ Fortnight/ Four Weeks £ Week/ Fortnight/ Four Weeks £ Week/ Fortnight/ Four Weeks £ Week/ Fortnight/ Four £ Week/ Fortnight/ Four Weeks £ *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. Evidence of all expenses must be provided to & verified by the Officer conducting the Interview Your Spending How (Please Circle) Amount? Company & Reference/ Account Number Documents seen by Officer 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 Amount? Documents seen by Officer Rent or Mortgage £ Council Tax £ Utility Bills £ Bank Loans £ Credit Store Cards £ Other (Specify) ……………………. £ Please provide proof of monies owing. Final Demands/ Court Orders details/instalments ______________________________________________________ ______________________________________________________ Your Capital & Savings Company & Reference/ account number Amount? Documents seen by Officer Savings Accounts £ Stocks/ Shares Number held: £ Other (Specify) £ Do you own property? YES / NO If Yes, please provide details of all the properties you own Your Property Address & Post Code Mortgage Balance Documents seen by Officer UK £ £ UK £ £ Overseas £ £
how the increase will be paid. Any increases will be discussed with Care Professionals following a review of the Resident’s personal budget. I understand that if I default on the top-up payment the East Lincolnshire Clinical Commissioning Group may take action against me. Defaulting on payment may result in the Resident’s accommodation being terminated and alternative accommodation arranged. The top-up payment must not normally be derived from the Resident’s savings or capital unless property is subject to a 12-week disregard or the costs of their care are being met through a Deferred Payment Agreement. A top-up payment must be paid in addition to any assessed contribution, the contribution the Resident may be assessed as due to make following a financial assessment (where a financial assessment is appropriate). I understand my responsibilities, as set out within this Declaration, and the Top-up Contribution Agreement dated [ enter date ]. Signed…………………………………………………. Dated______/______/______ Print name……………………………………………… Address………………………………………………… TOP-UP CONTRIBUTION AGREEMENT FOR SOCIAL CARE ACCOMMODATION THIS AGREEMENT is made on the [ date ] between North East Lincolnshire Clinical Commissioning Group (hereinafter referred to as ‘the NELCCG’) of Athena Building, 5 Saxon Court, Gilby Road, Grimsby DN31 2UJ of the first part and [ ] (hereinafter referred to as “the Provider”) of [ provider’s address ] of the second part and [ top-up ] of [ address ] of the third part (hereinafter referred to as “the Third Party” – delete if appropriate). WHEREAS [ name of the person with needs ] of [ address ] (hereinafter called “The Resident”) wishes (or a representative on his/ her behalf wishes it- delete if not relevant) to reside in a care home/ supported living accommodation (delete as appropriate) called [ ] (hereinafter referred to as “The Home”) which is operated by the Provider. The Provider is willing to provide the Resident with care under and in accordance with the terms and conditions of the Contract (as hereinafter defined).
Signed: ……………………………………………….. (Signature of Provider’s representative) On behalf of: [ ] (Provider) Signed: ……………………………………………….. (Signature of person making the Top-up Contribution)