Universal Credit | DHP Application Form

About You

First Name

Surname

Date of birth - optional

National Insurance No. (No Spaces)

House No.

Address line 1

Address line 2 - optional

Town/City

Postcode

Home phone No. - optional

Mobile phone No.

Email address

About Your Landlord

Landlord or their agent's name

Landlord or their agent's contact phone No.

Landlord or their agent's email address - optional

Employment Related Circumstances

Claimants who have been able to pay their rent when their tenancy first began and have not claimed Housing Benefit or Universal Credit Housing Costs in the last 12 months, may be entitled to receive a payment which covers the shortfall in the rent between the LHA and their actual rent charge for a period of 13 weeks. After 13 weeks this will be reviewed.

Have you received help with your rent from Housing Benefit or Universal Credit within the last 12 months?

Yes

Your Income and Savings

If you or your partner (if any) currently have savings please confirm the total amount (we may ask you for proof of this)

If you or your partner (if any) are currently in receipt of any other payments DLA/PIP/AA or similar - please confirm how much in total

Medical or Special Circumstances - optional

Please tell us about any medical / special circumstances that affect your need to live at this address (family support received or provided, access to hospitals or medical facility for you or a family member etc.)

Rent Details - tick all that apply

If your Universal Credit does not cover your rent charge have you asked your landlord if they would consider a reduced payment?

Are you at risk of eviction because of rent arrears?

Could you move to cheaper accommodation?

How long have you lived at this address?

Years

Months

DECLARATION: Please read the following carefully

I declare the information I have submitted is correct and complete to the best of my knowledge. I understand that action may be taken against me if this information is found to be incorrect or incomplete. I agree to report any changes in my circumstances that will affect my award of Universal Credit Discretionary Housing Payment, namely:

if I change address
if there is a decrease in my rent charges
if I stop receiving the housing element in my Universal Credit award

I confirm that I have understood and agree to the above declaration

Discretionary Housing Payment

Application for Universal Credit claimants

Click here if you require further information on Universal Credit Discretionary Housing Payment.

Do you live in Northern Ireland?

Have you been awarded Universal Credit with housing costs?