Tell us who you are

Title Firstname Surname Are you male or female Date of birth Address line 1 Address line 2 Address line 3 Address line 4 Postcode National insurance number Daytime telephone number Mobile telephone number Email address

Reference number:SIJCGSOV
Mrs marion kehoe Female 11/05/1954 the granary springfield farm yieldshields road carluke ML8 4QZ YT450000C 01555812090

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About your claim

What is your current living situation: When did you buy your property (dd/mm/yyyy)? When did you move into this address (dd/mm/yyyy)? Are you a joint owner? Do you pay Council Tax? Please tell us your council tax account number Do you have a partner? What do you want to claim? Are you receiving any of the following? (If not, please leave blank) Who has completed this form? Please tell us how you found out you could claim

Reference number:SIJCGSOV
I own my home 31/08/2005 31/08/2005 j Yes n k l m n i No j k l m i Yes n j k l m n j No k l m

j Yes n k l m n i No j k l m Housing Benefit and/or Council Tax Benefit Employment and Support Allowance (IR) Claimant Benefit leaflets i Yes n j k l m n j No k l m annekehoe3@tiscali.co.uk j Yes n k l m n i No j k l m i Yes n j k l m n j No k l m 01555812090 j Yes n k l m n i No j k l m i Yes n j k l m n j No k l m j Yes n k l m n i No j k l m j Yes n k l m n i No j k l m

When we need to speak to you about your claims, but we do not need to send you a letter, how would you like us to communicate with you? By email What is your email address? By mobile text message By phone What is your phone number? By Minicom By Letter At my local Council Information Service office Other

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About you
Name: marion kehoe
Have you moved address in the last twelve months? Have you claimed housing benefit or council tax benefit before?

Reference number:SIJCGSOV

j Yes n k l m n i No j k l m i Yes n j k l m n j No k l m

When did you claim (dd/mm/yyyy)? Did you use a different name in your last claim? Did you claim from South Lanarkshire Council? Have you come to live in England, Northern Ireland, Scotland, Wales, the Channel Islands or the Isle of Man in the last 2 years? What is your nationality? Are you a student? an apprentice on youth training in legal custody severely mentally impaired registered blind long term sick disabled Are you temporarily living away from home?

05/04/ 2012 j Yes n k l m n i No j k l m i Yes n j k l m n j No k l m j Yes n k l m n i No j k l m British j Yes n k l m n i No j k l m j Yes n k l m n i No j k l m j Yes n k l m n i No j k l m j Yes n k l m n i No j k l m j Yes n k l m n i No j k l m j Yes n k l m n i No j k l m i Yes n j k l m n j No k l m i Yes n j k l m n j No k l m j Yes n k l m n i No j k l m

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Children

Reference number:SIJCGSOV

We need to know about any children who normally live with you and who you or your partner get child benefit for or have applied for child benefit for. You may be able to get more benefit if there are children in your household and they are: Under 16 Aged 16 or 17 and registered for work or youth training; or l Aged 16, 17, 18 or 19 and in education doing a course not higher than GCE A-Level, SCE Higher level or GNVQ (advanced).
l l

Are there any children in your household that fit into the above categories?

j Yes n k l m n i No j k l m

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Other people
Do any adults usually live with you and your partner? Has anyone left your household in the last 12 months?

Reference number:SIJCGSOV

For housing benefit and/or council tax benefit, anybody who lives with you apart from your partner, or children, is called a non-dependant. Anyone who lives with you can also be a boarder, or a joint tenant, as well as a non-dependant. This section asks questions about any non-dependants who live with you, and it also asks for details about the property you live in.

j Yes n k l m n i No j k l m j Yes n k l m n i No j k l m

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Special circumstances
Are you or your partner waiting to hear about a claim for Jobseekers Allowance (IB), Income Support, Employment Support Allowance (IR) or Guaranteed Pension Credit?

Reference number:SIJCGSOV
j Yes n k l m n i No j k l m

Name: marion kehoe

Are you in hospital at the moment? Do you receive Disability Living Allowance care component?

j Yes n k l m n i No j k l m i Yes n j k l m n j No k l m

Do you receive the lower, middle or higher rate? Do you receive Disability Living Allowance mobility component?

Middle i Yes n j k l m n j No k l m

Do you receive the lower or higher rate? Do you get Attendance Allowance? Does anyone get Carers Allowance for looking after you? Do you have a vehicle from a Mobility scheme? Do you pay towards the upkeep of a student?

Higher j Yes n k l m n i No j k l m j Yes n k l m n i No j k l m j Yes n k l m n i No j k l m j Yes n k l m n i No j k l m

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Anything else
I give South Lanarkshire permission to talk to someone else (eg. a relative, carer, social worker, friend etc.) about my claim? Use the box below to tell us anything else you think we should know about.

Reference number:SIJCGSOV
j Yes n k l m n i No j k l m I claimed c t benefit in april last year, and kept you well informed that I was waiting on information from the bank(which you requested) and sent it in to you as soon as I recieved it, I thought you were dealing with it and the next thing I knew was that I recieved a letter from you saying that I wasn't recieving c t benefit, the letter was dated 04/08/2012. I would be grateful if you could consider benefit from 05/04/2012 i Yes n j k l m n j No k l m 05/04/2012 as above

Do you want us to consider paying your benefit from an earlier date? Date you want to claim benefit from (dd/mm/yyyy) Use the box below to tell us why you have not claimed before

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Evidence

PLEASE NOTE - WE WILL NOT BE ABLE TO PROCESS YOUR CLAIM UNLESS WE RECEIVE THE REQUIRED EVIDENCE SPECIFIED BELOW. PLEASE SUBMIT THIS EVIDENCE AS SOON AS POSSIBLE.

Reference number:SIJCGSOV

Based on the information you have provided within this online form we will need to see the following documents in order to complete and process your claim.

Evidence of identity We need to see one of the following forms of identity: UK passport Driving Licence (both photo card and paper copy) l Birth Certificate
l l

Evidence of national insurance number Such as P45, P60, wage/salary statement, tax letter, Department for Work and Pensions notification letter, National Insurance card, a benefit book (but not Child Benefit), for self-employed people a bank statement showing Class 2 national insurance payments paid by direct debit - providing it shows your N.I. number. We need to see one of these documents. Please return the above evidence to South Lanarkshire Council, Benefits Processing Centre, 45 John Street, Blantyre, G72 0JG Evidence of Income Support, income-based Jobseekers Allowance, income-based Employment and Support Allowance and Pensioner Guarantee Credit Such as a benefit payment book showing the current address and the amount received.

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Equalities

Please select which best describes your ethnic origin. Your ethnic origin is not related to your nationality, place of birth or citizenship. It describes your colour and general ethnic group. UK citizens can belong to any of the groups shown below. Please also give your preferred language or languages and any details of your disability. You do not need to fill in this page to claim benefits, but it will help us assess whether we providing an equal and fair service.

Reference number:SIJCGSOV

Ethnic origin
Please tell us your ethnic origin.

Languages spoken and written

If English is not your main language, please tell us which language you speak and write.

Urdu

Spoken Written

j Yes n k l m n j No k l m j Yes n k l m n j No k l m

Gujarati

Spoken Written

j Yes n k l m n j No k l m j Yes n k l m n j No k l m

Bangladeshi

Spoken Written

j Yes n k l m n j No k l m j Yes n k l m n j No k l m

Kashmiri

Spoken Written

j Yes n k l m n j No k l m j Yes n k l m n j No k l m

Punjabi

Spoken Written

j Yes n k l m n j No k l m j Yes n k l m n j No k l m

Chinese

Spoken Written

j Yes n k l m n j No k l m j Yes n k l m n j No k l m

French

Spoken Written

j Yes n k l m n j No k l m j Yes n k l m n j No k l m

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Arabic

Spoken Written

j Yes n k l m n j No k l m j Yes n k l m n j No k l m

Somali

Spoken Written Other

j Yes n k l m n j No k l m j Yes n k l m n j No k l m j Yes n k l m n j No k l m

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Declaration
Review your answers
Before submitting your form you can review all of the answers you have given so far by clicking on the link below. Open a read only view of the answers you have given (this will open in a new window)

Reference number:SIJCGSOV

Summary
A brief summary of the information you have provided can be viewed using the link below. Please click on the link below to get to the summary page. Open the summary (this will open in a new window)

Claim Form Checklist

A complete list of required evidences is available from the link below. Claim form checklist (this will open in a new window)

Your Declaration
You must read the declaration and confirm that you have read and understood it, and that all the details you have provided are correct. Please click on the link below to get to the declaration page. Open the declaration form (this will open in a new window) I declare the information I have given on this form is correct and complete, and that I have read and agree to the declaration

b c d e f g

Printing the documents on this page

You should retain a hard copy or electronic copy of the documents on this page. If you wish to retain hard copies, but do not have access to a printer or are unable to rpint the documetns for any reason, please tell us using the options below. We will send you them through the post.

i I have printed the documents on this page j k l m n j I am unable to print the documents on this page. Please send k l m n me a copy in the post.

What to do next
You can can now submit your application form by clicking on the submit button below. You should send any other forms and your evidence to: South Lanarkshire Council Benefits Processing Centre John Street Blantyre G72 0JG

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 HOUSING/COUNCIL TAX BENEFIT CLAIM RECORD OF EVIDENCE & CROSS CHECKS The following checks should be completed and recorded as completed prior to claims processing:

Reference number:SIJCGSOV

Check Have items of evidence as specified in the framework been supplied? Has each item been authenticated, photocopied or recorded and signed? Has NI/DOB been validated? (if yes, state type of document seen in comments column) If evidence specified in the framework is not available, has confirmation from and alternative source been obtained and details recorded on file?

Y/N

Comments (if applicable)

Have all cross checks been completed (including CIS check)?

If evidence specified in the framework is not available, has confirmation from and alternative source been obtained and details recorded on file? Have all cross checks been completed (including CIS check)? Name of Benefit Assessment Officer (block capitals): Signature of Benefit assessment Officer: Date: This application form was started on 14/01/2013 12:15:09 This application form was submitted on 14/01/2013 12:57:14

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