Rent Allowance Sample Form

TYPE OF TENANCY
- Sole Tenant of Property/Room?YES NO
If NO - Joint Tenant with whom?.......................................
- Housing Association Tenancy? YES NO If NO PLEASE ANSWER THE FOLLOWING QUESTIONS:
1. Is your Landlord the ex-partner of you or your current partner? YES NO
2. Do you share the accommodation with your landlord? YES NO
3. Are you/your partner the owner or part owner of the above address? YES NO
4. Have you/partner ever been the owner of this property? YES NO
5. Are you or any member of your household related to the landlord or his partner ? YES NO
6. Have you/partner lived at this address before the commencement of this tenancy ? YES NO
7. Do you/partner rent the accommodation from:
(a) Company of which you, your partner, your ex-partner, your partner’s ex-partner,
or a close relative who lives with him is a director ? YES NO
(b) Company of which you, your partner, your ex-partner, your partner’s ex-partner,
or a close relative who lives with him is an employee ? YES NO
(c) A trust of which you, your partner, your ex-partner, your partner’s ex-partner,
or a close relative who lives with you is a trustee or beneficiary ? YES NO
(d) A trust of which your, or your partner’s child is a beneficiary ? YES NO
8. Do you/partner rent your home as a condition of your employment? YES
NO
If you have answered yes to any of the above, please provide full details on a seperate sheet.
Claimant’s name....................................................… Landlord or Agents name .......................................
Partner’s name...................................................................................................
Address .................................................................… Address .................................................................…
................................................................................… ........................................................................
Postcode ...............................................................… Postcode..................................................................…
Tel No ......................................................................… Landlord/Agent’s Tel No ............................................
Date moved in ........................................................… Date of Tenancy (if different) ...................................
Previous Address .........................................................................................................................................…
DOES THE RENT INCLUDE PAYMENTS FOR THE FOLLOWING?
Please tick and enter amount if known
Council Tax YES NO £_______ Laundry Facilities YES NO £_______
Water Rates YES NO £_______ Personal Care YES NO £_______
Lighting YES NO £_______ Counselling/Support YES £_______
Hot Water YES NO £_______ Who washes your clothes? Landlord Self £_______
Cooking Fuel YES NO £_______ Who washes your bedlinen?Landlord Self £_______
Heating YES NO £_______ Who cleans your room? Landlord Self £_______
Garage YES NO If YES: Do you have the option to rent the Garage separately ? £_______
How much is your rent? £ Monthly/Fortnightly/Weekly/4 Weekly
Do you have Rent Free Weeks? YES NO If yes how many? ________________
RA1
RENT ALLOWANCE CLAIM
DO NOT DELAY IN RETURNING THIS FORM TO THE HOUSING BENEFIT SECTION
- Ty Elwyn, Llanelli, SA15 3AP 01554 742100
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Rent Allowance Sample Form PDF

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