This form is to be completed by a household member in conjunction with a claim for Housing Benefit/Council Tax Reduction.

If you are a 3rd party completing the form on behalf of the claimant, then please fill in the form as though you are the claimant yourself. Once the information is completed the claimant will need to read and sign a declaration confirming that the information provided is correct and true.

In order to complete the form, you will need:

  • The name and address of the claimant
  • The dates which the claimant has had nil income
  • Weekly expenditure for the claimant