Please complete this form if you are getting Housing Benefit and wish to be considered for an award of Discretionary Housing Payment from the Housing Executive. A Discretionary Housing Payment can only be awarded by the Housing Executive to tenants where their award of housing benefit is affected by one (or more) of the following:

1. A rent restriction (for private tenants).
2. The ‘Family Premium’ not being included in their housing benefit calculation because of a change in the law in September 2016.
3. For ‘Benefit Cap’ legislation where the amount of a person’s benefit cap is increased but their Welfare Supplementary Payment remains the same.

Housing Executive and housing association tenants can only be considered for a Discretionary Housing Payment because of ‘Family Premium’ or ‘Benefit Cap’. You cannot, for example, qualify for Discretionary Housing Payment if your housing benefit has been reduced because of an increase in household earnings, a change in the number of people living in your household, a non-dependant has moved in or you are paying back an overpayment.

Please complete the following

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Personal Data:

The Housing Executive protects your personal information in accordance with General Data Protection Regulation and Data Protection Act 2018. You have a right to know how we collect and use your personal information. These details can be found in our Privacy Notice which is on our website www.nihe.gov.uk/privacy_notice. We can post or email a copy to you.

DECLARATION: Please read the following carefully

I declare that the information I have given on this form 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; or
• I fail to report any changes in my circumstances which may affect any award of Discretionary Housing Payment that I may receive.