Change in circumstances

This form is for you to use if you have a change in circumstance whilst your claim is in payment.

Note: Those questions marked with an * must be completed.

Benefits claim ref. no. (if known)

Name

Title
If Other, please specify
First name(s) ^*
Surname ^*

Date of birth ^*

Address

Prefix e.g. first floor flat.
House name/number
Street
Village/Area e.g. Scawby, Bottesford, etc.
Town
County
Post code ^*Please input your post code using capitals and include a space between the first and second parts e.g. DN17 5TY.

Daytime tel. no.

Email address

Note: on submitting your completed form, if you have provided a valid email address above you will automatically receive a copy of your completed form.

Date your circumstances changed ^*

Who does the change affect? (Please provide the name and date of birth of all the person(s) affected by the change) ^*

What is the change? (You will need to provide documentary evidence of this) ^*

I agree to provide documentary evidence of this change within the next 7 days. More information on the type of evidence you need to provide can be found in the Housing and Council Tax Benefit claim form.

Please tick the box to agree to the above statement ^*

I agree

The information on this form is true and complete. This information, together with the information on my claim form, correctly represents my circumstances as they are at the present time. I will report any other changes in my circumstances to the council.

Please tick the box to agree to the above statements ^*

I agree

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