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Part 4 About rent - continued

Living away from home

91. Are you living away No Q
from home at the Yes, Q Tell us why you are not living at home
moment?

Tell us where you are living at the moment.

Support charges declaration ■ only complete if you are liable to pay support
charges

I confirm that I am liable to pay support charges as well as my rent and understand that I may receive help with these charges.
I understand that the amount I am required to pay can vary and may be reduced if I receive housing benefit or a fairer charging
assessment.

I authorise the Council's Housing Benefits Office to work with the Supporting People Team and the Fairer Charging Section and
to exchange information about me in order to work out whether I can receive additional help with my support charges.
I confirm that I have been informed that from 1 April 2003 any help towards my support charges will be paid direct to my landlord
or support provider, and that I agree to the Supporting People Team liaising with my landlord or support provider in relation to
these payments.

I understand that I may withdraw my consent to this arrangement at any time by notifying the Supporting People Team in writing
of my decision. I further understand that if I decide to take this course of action then I will become responsible for notifying the
Housing Benefit Office, the Fairer Charging Section and the Supporting People Team separately in writing of any change in my
circumstances.

Signature of Claimant

Date

only complete if you are liable to pay support charges

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