Backdate Application

Claimant Details

Claim Number

Can be found on any letter we have sent you and begins with a "2"

First name

Surname

Telephone number

National Insurance number

Address

Postcode

Are you... (please select)

An Owner/OccupierA Private TenantA Housing Association Tenant (such as Cross Keys or Accent)

Do you want to claim for... (please select)

Housing BenefitCouncil Tax SupportBoth Housing Benefit and Council Tax Support

Period Benefit(s) Required

Housing Benefit

From

DD/MM/YYYY

Council Tax Support

From

DD/MM/YYYY

Please advise why you have been unable to claim before this date - you must show good cause for the delay in claiming for the entire period, from the "From" date quoted above until today.

Has this form been completed by someone other than the person named at the top of this form?

YesNo

Name

Relationship to the person claiming

Declaration

I understand the following:

If I give information that is incorrect or incomplete, you may take action against me.
You will use the information I have provided to process my claim for Housing Benefit or Council Tax Support, or both.
You may check some fo the information with other sources within the Council, Rent Offices and other Councils.
You may use any information I have provided in connection with this, and any other claim for Social Security benefits that I have or may make. You may give some information to other Government organisations, if the law allows this.

I know I must let the Council know about any changes in my circumstances which may affect my claim.

I declare the information I have given on this form is correct and complete.

I have read, understood and agree to the above statement

Yes

Privacy Statement

Peterborough City Council abides by the principles of data protection and information is collected, processed and stored in compliance with data protection legislation.

For more information then please see our privacy notice on who we may work with and how we may use your data. It can be viewed online at https://www.peterborough.gov.uk/council/council-data/corporate-privacy-notice/ or a copy is available at all council offices.