HB3 - Change-of-address form for private tenants

Revenues and Benefits
Council Offices
South Street
Rochford
Essex
SS4 1BW
Phone: 01702 318197 or 01702 318198
Email: revenues&[email protected]
Name:
Address:
Postcode:
Change of address form
for private tenants
This form is for you to tell us about your change of address. We need to know about all the
changes to your tenancy, household and rent. The form explains what you and we have to do
when you move into private rented accommodation.
Please do the following.
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Look at the checklist on page 10 (section F) for the types of proof you will have to
give us with this form.
Read and sign the declaration on page 11 (section G) before you return this form
to us.
Fill in this form in black ink. Do not use pencil.
Answer all the questions.
Tick the ‘Yes’ or ‘No’ boxes. Do not put crosses in or leave boxes blank.
Give us original documents only. We do not accept photocopies.
If you need help to fill in this form, or you have a question for us, please come to our
office at the address shown above, phone us on 01702 318197 or 01702 318198, or
email us at revenues&[email protected]
Remember


Return your filled-in, signed form to us straightaway.
You must give us any proof (that you have not sent with this claim form) within one
month of us sending this form to you.
For office use only
Date of contact
/
/
Claim number
Date of issue
/
/
C/Tax ref
Date received
/
/
1
Section A
About your home
Please give the full address and postcode of the property you are claiming Housing Benefit or
Council Tax Support, or both, for.
Do you rent from a:
housing association?
private landlord or
estate agent?
Please give us the name and business address of your landlord.
Name
Address
If an estate agent is acting for your landlord, please give the estate agent’s name and
business address.
Name
Address
What date did your last tenancy end?
/
/
What date did your new tenancy start?
/
/
What date did you move into your home?
/
/
Are you a boarder or subtenant?
A boarder is a person who lives in someone’s home and pays
them for rent and meals.
A subtenant is a person who lives in someone’s home and has
a written agreement to pay rent.
2
Yes
No
Section A (continued)
About your home
Are you a joint tenant?
Yes
No
Are you responsible for paying the Council Tax for your home?
Yes
No
Is it your main or only home?
Yes
No
If yes, please give the names of the other joint tenants.
If no, please give the full address and postcode of your main home.
Tick one of the boxes below to show the kind of accommodation you live in.
Detached house
Semi-detached house
Terraced house
Detached bungalow
Semi-detached bungalow
Terraced bungalow
Purpose-built flat
Converted flat
Flat over a shop
Rooms in a house
Maisonette
Hostel
Other
(please tell us what kind of accommodation you live in)
Does your home have:
central heating?
Yes
No
a garden?
Yes
No
a garage?
Yes
No
parking space for a car?
Yes
No
3
About your home
Section A (continued)
How many floors are in your home?
Which floors do you live on, for example, ground, first or second?
Please tell us about the rooms in your home.
Living
rooms
Bedrooms
Bed-sitting
rooms
Kitchens
Bathrooms
Toilets
Tell us the
number of
rooms there
are in the
whole
property
Tell us the
number of
rooms used
just by you
and your
family
Tell us the
number of
rooms you
share with
other people
How many people do you share your home with?
Do you need a bedroom for any carers who stay with you?
Yes
Who is responsible for furnishing your home?
You
Your landlord
partly furnished?
unfurnished?
Is your
home
fully furnished?
£
How much is your rent?
How often do you pay it, for example, weekly, four-weekly,
monthly or yearly?
4
No
Others
About your home
Section A (continued)
Does your rent include any of the following?
Yes
No
How much do
you pay
(if you know)?
Lighting your home
£
Lighting shared areas
£
Hot water
£
Gas or electricity for cooking
£
Heating
£
Cleaning your home
£
Cleaning shared areas
£
Laundry
£
Personal laundry
£
Council Tax
£
Water charges
£
Breakfast
£
Lunch
£
Evening meal
£
Gardening
£
Does your rent include counselling, support
(for example, a warden or a personal alarm system),
medical nursing or other care services?
Yes
No
If yes, please tell us below what your rent includes.
Is there anything else included in your rent, for example, window
cleaning or lift or building maintenance?
If yes, please tell us below what else is included.
5
Yes
No
About your home
Section A (continued)
Yes
No
Yes
No
Do you have any children from a relationship with your landlord?
Yes
No
Do you share the property with your landlord?
Yes
No
Yes
No
Yes
No
Is your landlord related to you or anyone who lives with you
If yes, please say how they are related. Some examples are
sister, mother and brother.
Did you, or anyone who lives with you, know your landlord
before your tenancy started?
If yes, how did you or they know your landlord?
If yes, please tell us what rooms in the property you share with
your landlord.
Do you pay your rent direct to your landlord?
If no, who do you pay your rent to?
Please give their name, address and phone number below.
Section B
Other changes
Have you had any other changes in your circumstances, for
example, a change in your income or savings, or someone
has moved in or out of your home.
If yes, please tell us about your changes in the box below.
6
Section C
C1
Housing Benefit Payment
Payment to you
We pay Housing Benefit by Bacs. This means we pay your Housing Benefit into your bank or
building society account. This is a safer way of being paid and you do not have to wait for the
payment to clear.
You must tell us your bank or building society account details. We cannot pay into a post
office account or a building society savings account.
What is the name of the bank or building
society you want your Housing Benefit
paid to?
What is the address and postcode?
Whose name is the account in?
What is the account number?
What is the sort code?
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-
Please make sure your account number is correct and written clearly, or we may not be
able to pay your benefit into your bank account.
7
Section C (continued)
C2
How do you want to be paid?
Payment to your landlord
If you rent your property from a housing association, or pay rent for a
mobile home, we can pay your Housing Benefit to your landlord.
If you want your benefit to be paid direct to your housing association or mobile-home park,
you and your landlord must sign this section.
I (the landlord) agree to accept direct
payment of Housing Benefit for
Tenant’s name
I agree to tell you as soon as the tenant moves out of the property, or if I believe that they
are no longer entitled to the amount of Housing Benefit they receive. I will pay you any benefit
I receive which the tenant is not entitled to.
If you pay me Housing Benefit after the date the tenant moved out, I will repay the money or
allow it to be taken from any payments you make to me in the future, whether or not the
tenant has any rent arrears.
I understand that you can ask me for rent statements, which show that Housing Benefit has
been paid to the tenant's rent account. I understand that I must keep records of rent accounts
and that you cannot get involved in disputes between me and the tenant.
Landlord’s signature
Date
/
/
Date
/
/
Landlord’s name
(in CAPITALS)
Tenant‘s signature
Tenant’s name
(in CAPITALS)
If you rent your property from a private landlord, we have to pay the
benefit to you, not them. In certain circumstances where you find it hard to
deal with your money, we may be able to pay your landlord.
Do you want us to pay your landlord?
Yes
No
If yes, we will send you a form to fill in. This will help us decide whether we can pay your
landlord.
8
Section D
Sharing information with your landlord
Under the Data Protection Act 1998 we must have your permission before we can share
information about you.
If you give us permission, we can tell your landlord:

whether or not you have claimed Housing Benefit;

whether we have decided to pay you Housing Benefit; and

that we need more information from you before we can decide whether to pay you
Housing Benefit.
There may be other information about your claim that we need to check with your landlord
(such as the date your tenancy started), before we can pay you Housing Benefit. We can ask
your landlord for this information even if you have not given us permission.
We can also talk to your landlord about any Housing Benefit we have overpaid them. We will
not discuss anything else with your landlord without your permission. We will not give your
landlord any information about your personal circumstances.
If you do not give us permission to share information about your claim with your landlord, it
will not affect your claim.
If you give us permission but then change your mind, phone us on 01702 318197 or
01702 318198 or email us at revenues&[email protected]
If you want to give us permission to discuss your claim with your landlord, please sign below.
I give you permission to share information about my Housing Benefit claim with my landlord or
their estate agent.
Your signature
Section E
Date
/
/
Claiming Council Tax Support
If you were not getting Council Tax Support at your last address and you want to claim
Council Tax Support for this address please sign below.
Your signature
9
Checklist
Section F
We must see original documents, not copies. If you do not provide all the proof we need,
we may not be able to pay you any Housing Benefit.
If you cannot send the proof we need, send the form back to us now and send the proof to us
within one month. We can start to work on your claim, but we will not be able to pay you
any Housing Benefit until we have all the proof we need.
Please tick the box to show which documents you are sending with this form.
We must see the following.
Your tenancy agreement (the original, not a copy) or proof of your last
rent increase.
The notice of registration form (RO5) if you have a protected or regulated
tenancy (that is, your rent has been agreed by the Rent Service),
A letter from your landlord or their agent that shows:

how much rent you pay;

how often you pay your rent;

when the tenancy started; and

which services, if any, are included in your rent.
About people you rent rooms to
We need to see proof of the rent you are charging them every week or month.
For example, a rent book or an up-to-date rent statement.
Data protection
We will keep the information you have given us confidential. We will store it on a computer
and use it to deal with your benefit claim. We will only give your details to someone else if we
are asked to by law. This is in line with the Data Protection Act 1998.
Preventing fraud
We must protect the funds we manage. We may use the information you have provided on
this form to prevent and detect fraud. We may also share this information with other
organisations that manage public funds, to prevent and detect fraud.
If there is any other information you think we may need to be able to deal with your
claim, please tell us in section B.
10
Declaration
Section G
Please read this declaration carefully.

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
The information I have given on this form is true, and I have given as much information as
I can.
You can check the information I have given.
I will write to you to tell you straight away about any changes to my financial or family
circumstances, or change of address.
I can be prosecuted if any of the information I give is untrue, or if I do not give you any
information that I have and that is relevant to my claim.
When you have filled in this form, please read the form again and check that you have sent
us all the proof we have asked for.
Finally, before you send the form to us, please read this declaration again and sign it and
fill in the boxes below.
You
Your partner
Your signature
Your signature
Your full name
(in CAPITALS)
Your full name
(in CAPITALS)
Date
Section H
Date
If you have filled in this form for someone else
You must fill this section in if you have filled in this form for someone else.
Your name
Your address
Your signature
Your phone number
Your relationship to the person claiming
Housing Benefit or Council Tax Support,
or both. Examples include ‘friend’ and ‘agent’.
Date
/
11
/
If you need free and independent advice you can contact one of the
following agents.
Citizens Advice Bureau
Opening Times for Initial Assessments:
Rochford Office, Back Lane, Rochford SS4 1AY
Open Tuesday
10.00am–2.00pm
Open Thursday
10.00am–2.00pm
Phone: 0344 477 0808
Rayleigh Office, Civic Suite, Hockley Road, Rayleigh SS6 8EB
Open Monday
10.00am–2.00pm
Open Thursday
10.00am–2.00pm
Open Friday
10.00am–2.00pm
Phone: 0344 477 0808
Tribunals Services
www.appeals-service.gov.uk
If you need help filling in the form
You can phone us on 01702 318197 or 01702 318198 between 8.30am to 5.30pm, Monday to
Thursday and 8.30am to 5.00pm Friday.
You can come to our offices between 8.30am to 5.30pm, Monday to Thursday and 8.30am to
5.00pm Friday.
We are closed at the weekend. Our address is on the front of this form.
If you would like this information in large print, Braille
or another language, please phone 01702 318111.
HB3
Typists/PRINT ROOM/CUSTOMER, REVS & BENS SERVICES/Benefit Forms 2016
12