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:
Please complete the following
Fields with a * are required
Are you responsible for a child or young person for whom you still receive payments of Child Tax Credit or Child Benefit? (Please tick)*
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) receive DLA, Personal Independence Payments or Attendance Allowance, Armed Forces Independence Payment please tell us how much in total this is:
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)
How often does this amount have to be paid? Please tick:*
If your Housing Benefit does not cover your rent charge have you asked your landlord if they would consider a reduced payment? Please tick:*
Are you at risk of eviction because of rent arrears? Please tick:*
Could you move to cheaper accommodation? Please tick:*
How long have you lived at this address?
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: