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    Home > Benefit Information Form

  • Benefit Information Form

    To complete this form you might need wage slips, your council tax bill, benefit letters and pension statements

    For us to give you benefit advice, you (and your partner) will have to consent to us holding information about any disabilities or long-term health issues you have

    Once the form is submitted, we will contact you to offer a telephone or face-to-face appointment. You might already have been given a date and time for this.

    Benefits Information
    We will keep your information on our system for six years and then delete it. You can read our privacy policy at https://www.midbedscab.org.uk/privacy-security/ *
    Your name *
    Your name
    First
    Last
    Can we text you? *
    Can we leave a voicemail? *
    Do you consent to us holding information about any disabilities or long-term health conditions you have? *
    4. Do you live with a partner/ husband/ wife etc? *

    Citizenship

    5. Are you *
    9. Is your partner *

    Your partner

    16. Does your partner have a disability or long-term health condition? *

    Please get your partner to complete the following:

    20. Name *
    20. Name
    First
    Last
    21. I agree to you holding information about my disabilities or long-term health conditions *

    About your household

    25. Do you have any 16-19 year old children living at home who are in education (up to A level)? *
    27. Do any of your children get DLA or PIP? *
    30. Are there any other people living with you? *
    33. Are you caring for anyone who is getting a disability benefit (DLA/PIP/AA etc) including any children? *

    About your earnings

    35. Are you self-employed? *
    37. How often *
    41. Are they self-employed?
    43. How often *
    45. Do you receive any
    45b. Does your partner receive any
    46. Do you (and your partner) have joint savings over £6000? *
    47. Do any of these savings come from the recent sale of your home, compensation for a personal injury or a bereavement payment? *
    48. Do you (or your partner) have assets apart from where you live? *
    49. Are you enrolled on any educational courses? *

    About your benefits

    50. Do you receive Universal Credit? *
    51. Do you receive Housing Benefit? *
    52. Do you (or partner) receive any of the following benefits? *
    52a. Do you know what type(s) it is?
    56. Do you get Carers Allowance? *
    57. Does your partner get Carers Allowance? *
    58. Do you get Pension Credit? *
    59. Do you get Child Benefit? *
    60. Do you get Child Tax Credit? *
    61. Do you get Working Tax Credit? *
    62. Do you get any other benefits not already entered? *
    63. Does your partner get any other benefits not already entered? *

    Previous year's income

    66. Do you expect your income(s) to be about the same this tax year? *
    69. Do you expect your partner's income(s) to be about the same this tax year? *

    Your housing costs

    70. Are you *
    71. Are you lodging with a family member (including in-laws)?
    72. Are you renting from *
    77. Are there any rent-free weeks? *
    78. What's your annual council tax bill? *
    79. Have you had a death in your family recently (e.g. your partner)? *
    80. If we can't contact you, can we email you your results? *
    81. Would you like us to refer you for any debt advice? *

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Citizens Advice Mid Bedfordshire is an operating name of Mid Bedfordshire Citizens Advice Bureau.
Registered Charity Number 1109976
Registered Company Number 5351800
Registered Office Century House, Market Square, Biggleswade, SG18 8UU
Authorised and regulated by the Financial Conduct Authority FRN:617668
Website last updated on 4 November 2024 © Copyright Mid Bedfordshire Citizens Advice Bureau | Web design by Moocow Media

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