Crisis and Resilience Fund Housing Payments Application

Name: 	
Address: 	
Telephone Number:	
Email Address:	
Housing Benefit Ref: 	National Insurance Number: 	
 Have you recently applied for Universal Credit (including the Housing Cost Element)

Yes   ☐	No ☐		

Please list all your household income
Type of Income	Amount

£	How Often Paid 
(e.g. weekly, fortnightly, monthly)	
Earnings (including self-employed)			
Earnings (partner)			
Child Benefit			
Child Tax Credits			
Working Tax Credits			
Disability Living Allowance			
Attendance Allowance			
Carers Allowance			
Personal Independence Payments			
Income Support			
Job Seekers Allowance			
Employment & Support Allowance			
Child Maintenance Payments			
Universal Credit (including Housing Cost Element)			
Other (please specify)			
What savings / investments do you or your partner have? 

•	Please list any accounts you have and the balances for each.
•	Please list any other savings / investments you hold (e.g. premium bonds, shares).

We may ask for proof of these.	

	
Please list all your weekly outgoings, if you are paying debts or arrears, please say when these will be paid off. We may ask for proof if amounts appear excessive.

Payment	Amount
£	Frequency of payment	Date ends (if applicable)	
Rent				
Council Tax				
Water Bill				
Electricity				
Gas				
Buildings/Contents Insurance				
Life Insurance				
Food / Household Products				
TV Licence				
Telephone				
Broadband / TV Package				
Clothing & Shoes				
School Meals / Trips / Nursery fees				
Travel costs (public transport)				
Petrol/ Diesel				
Road Tax / MOT				
Car insurance / Breakdown Cover				
Credit Cards / Other Debts				
Catalogues				
Pet Expenses				
Other Expenses (please list):

				

If you and / or your partner are disabled in any way, please tell us about any expenses (not already mentioned above) which you pay as a result of the disability.  	

	

Do you and / or your partner have any other financial help that you could rely on i.e. family or friends? If yes, please give details.	

	

Have you (or your partner) had experience in the past of being looked after in the care system?

Yes   	☐      No    ☐

Please describe any health problems that you or members of your family suffer from which may affect your request for a Crisis and Resilience Fund Housing Payment. 

Also confirm if:
•	You or any family member have overnight carers, and provide confirmation from your doctor or health professional as to why this is required. Also a letter from your carer to confirm their name, address and how often they provide overnight care; or

•	 You and a partner cannot share a bedroom for medical reasons. If so, please explain why; or

•	 You have children who cannot share a bedroom because of the medical condition of one of the children who receives either the middle or higher rate of Disability Living Allowance (care component). Please explain why they cannot share and provide a letter from a doctor or other professional confirming this.   	

	

Is there a particular reason why your accommodation is suited to the needs of you and your family? If so, please explain.	

	

Please answer the following if you pay rent (to the Council or a Private Landlord or Housing Association).

Are you in rent arrears and, if so, by how much? 			
Have you received a Notice to Quit and, if so, when?			
Have you made an arrangement with your landlord to pay any rent arrears?			
Have you contacted the Council’s Housing Advice Section for advice?
Telephone number: (01223) 457918 			
Have you registered on Homelink and, if so, are you actively bidding?			
Have you looked for other cheaper accommodation (in or outside of the City)?			

Thank you for completing the above, if there are any details that you feel may assist your application, please write them in the box below.

Additional Information.	

	

Please tell us how long you need Crisis and Resilience Fund Housing Payments for.	

	

Declaration

The information I have given on this form is true and complete and I will notify Cambridge City Council of all changes of circumstances that may affect my entitlement to a Crisis and Resilience Fund Housing Payment.

In making this application for a Crisis and Resilience Fund Housing Payment, I authorise:
•	Cambridge City Council to make all reasonable enquires to validate and substantiate this claim.
•	I also agree to the Council passing details of this application to the Citizens Advice Bureau and / or an Employment Advisor if a referral is made and to discuss the outcome of any referral. 

Any overpayment of a Crisis and Resilience Fund Housing Payment that is deemed recoverable will be repaid by myself.

Signature
		
Print Name
		
Date

If anyone helped you to complete this form please ask them to sign and date below.

Signature
		
Print Name
		
Relationship to Applicant		
Date

Payments

If a Crisis and Resilience Fund Housing Payment is agreed please let us know below who you wish the payment to go to. This would normally be either yourself or your landlord. In addition, please provide the bank details of the person who you wish to receive the payment.

Who would you like the payment(s) to go to?

Please provide the bank / building society details of the person you wish to receive the payment.

Where you have a building society account please include your Roll Number.	Name of Bank:

Sort Code:

Account Number:

Building Society Roll Number:

	
  
Water Bill Reduction

I confirm that I am the bill payer and I give permission for you to pass relevant personal details to the Cambridge Water Company (part of South Staffordshire Water) in order that they can potentially award me a 60% tariff reduction on my water bill. These details would be my name, my partner’s name if applicable and my address.
Signature
		
Print Name
		
Address
		
Date

Please return it to: Revenues & Benefits, Cambridge City Council, FREEPOST PO Box 130, Cambridge, CB2 1BR

Useful Contacts

Citizens Advice Bureau
	
Advice Line Freephone
The advice line is: 0808 278 7808 (Monday – Friday 9am to 5pm)

Website
www.cambridgecab.org.uk

You can also be referred to the CAB by our Customer Services Team. Please phone (01223) 457000

Child Maintenance Payments	
Child Maintenance Service is a free service that provides impartial information and support to do with child maintenance payments.

Telephone number: 0800 171 2345                                                                                   (Monday to Friday and 8am – 4pm)

Housing	
The Council’s housing advice service can be contacted by the following

Website
Go to Cambridge City Council’s website (www.cambridge.gov.uk) and type “Get advice about housing” in the “Search” field. Amongst others things here, you can:

o	Make an online enquiry about housing; or
 
o	Register with “Homelink”, which is how you apply for council or housing association accommodation.  

Further Assistance
If you are a Council tenant and need further assistance, you can phone (01223) 457000 and ask to speak to a Financial Inclusion Officer.

Lodgers	
If you have a spare room and are considering taking in a lodger, please speak to Town Hall Lettings from Cambridge City Council. 
He can advise you on how to go about doing this and what impact, if any, it will have on your benefits. 

Telephone number: (01223) 457912
Email: Accommodation.finders@cambridge.gov.uk

Disability-Related Benefits 	
The CAB can assist with both advice and applying for these benefits. Their contact details are above.

•	Attendance Allowance                                               (For those who have reached state pension age)
Telephone number: 0800 731 0122

•	Disability Living Allowance                                              (Typically for children aged under 16)
Telephone number: 0800 121 4600 (born after 1948)
Telephone number:0800 731 0122 (born before 1948)

•	Personal Independence Payments                        (For those aged 16-64). 
Telephone number: 0800 917 2222 

•	Carer’s Allowance                                          (providing care for someone for at least 35 hours per week).
Telephone number: 0800 731 0297

Taxi Card	
Taxicard is a scheme that helps disabled people on low incomes to pay for taxi journeys.

When you join you'll be given voucher worth up to £165 that you show to the taxi driver before every journey. 

Telephone number: 01223 457000

Email: taxicard@cambridge.gov.uk	

Prescription Prepayment Certificate	
If you know you’ll have to pay for a lot of NHS prescriptions it may be cheaper to buy a prescription prepayment certificate (PPC) – effectively a prescription 'season ticket'. A PPC covers you for all of your own NHS prescriptions, including NHS dental prescriptions, no matter how many items you need.

1.	A three-month PPC costs £32.05 and will save you money if you need more than three prescribed items in three months 
2.	A 12-month PPC costs £114.50 and will save you money if you need more than 12 prescribed items in a year 

Telephone number: 0300 330 1341