Online Claim Ref BH2-003-0E4 Date 22/4/2015Name Mr Jackson Baird National InsuranceNJE914584AAddress Flat 9 17 Portland Place Brighton BN2 1DHCouncil Tax Ref. N N/ATelephone N(mobile)07716052071 No Jackson Baird Mr No 09/10/1976 MaleClaim for Housing Benefit and Council TaxReductionBrighton & Hove CouncilYour claimThis summarises your official claim for Housing Benefit and Council Tax Reduction. Your answersnow cannot be changed. If you notice anything incorrect on this form you must inform the LocalAuthority immediately. If you make false statements or deliberately miss out information whichleads to you receiving more benefit than you should you may be prosecuted.This claim sheet also contains a list of evidence you must provide before we can acceptyour claim. You will not be asked for these separately.Please read through this document, as it contains important information about your claim.Claim Details Claimant Details Section A : Personal DetailsDo you live with a partner as a couple? Your first name(s) Your surname Your title Do you use, or have you ever used, any other names? Your date of birth (Enter year in the format YYYY) What gender are you? Yes, I know thenumber JE914584A British No No jaxbaird@gmail.com 07716052071 mobile renting from a privatelandlord Flat 9 17 Portland Place Brighton BN2 1DH main home nowDo you have a National Insurance number? What is your National Insurance number? (Enter NI Number inthe format AA999999A) What is your nationality?BritishNot British Have you come to live in the United Kingdom in the last fiveyears? Are you a student? By student we mean anyone who isattending a course of study at an educational establishment,including student nurses. Please enter your email address. Your telephone number What type of phone number is this? Section B : Your AddressWhat kind of home do you live in (or are going to live in)? Areyou:renting from Brighton & Hove Councilrenting from a housing associationrenting from another registered social landlord like a housing trustrenting from a private landlordan owner-occupiera boarder, with meals included in my rentin temporary homelessness accommodationcommercial lodgings, guest house or hotel What is the address you are making this claim for? Enter thepostcode with a space so it matches the format A1 1AA. Flat number/name House number/name Street name Town or city Postcode Is this your permanent main home now, or are you going tomove into it within the next few weeks? 18/04/2015 1st floor flat 54 Newick Road London E5 0RR 01/02/2015 renting from a privatelandlord or paying rentto live in part ofsomeone's home No No Yes No Yes 01/02/2015

YesWhen did you move into the address you are making this claimfor? What address did you live at previously? Enter the postcodewith a space so it matches the format A1 1AA. Flat number/name House number/name Street name Town or city Postcode What date did you move out of your previous address? (Enteryear in the format YYYY) At your previous address were you:renting from a councilrenting from a private landlord or paying rent to live in part ofsomeone's homerenting from a housing association or registered social landlord likea housing trustan owner-occupierliving with relatives or friendsliving in commercial lodgings, a guest house, hostel, hotel or bedand breakfastother Are you in legal custody (such as in prison, on remand, youthoffenders centre)? Are you temporarily living away from home? Do you use any part of your home for running a business? Do you rent another home somewhere else - in this country, orabroad? Have you claimed Housing Benefit, Council Tax Benefit orCouncil Tax Reduction in the past? If you claimed it but did notget it, please say Yes. When did you last claim Housing Benefit, Council Tax Benefitor Council Tax Reduction? (Enter year in the format YYYY) What was your previous Housing Benefit Reference number? Was your last Housing Benefit, Council Tax Benefit or CouncilTax Reduction claim for the same address as you are claimingfor now? Hackney Yes flat in a block of flats 2nd Floor at the left middle No Yes No No No You or Your Partner 5 No 1 1 0Which council did you make your last claim for HousingBenefit, Council Tax Benefit or Council Tax Reduction from? When you last claimed Housing Benefit, Council Tax Benefit orCouncil Tax Reduction, did you use the same name as youhave given for this claim? Section C : AccommodationWhat sort of accommodation do you live in? Where is the flat? Which floor or floors do you live on? As you look at the building from the street, where in thebuilding do you live?at the leftat the right Which part of the floor or floors in the building you occupy, doyou live in? Within the last 5 years did you previously own the home youare claiming for, but have sold it? Does your home have central heating? Does your home have a garden? Does your home have a garage? Does your home have a parking space? Who is responsible for decorating your home?You or Your PartnerYour LandlordShared between You/Your Partner and Your Landlord How many floors are there in the building? We mean the wholebuilding, not just the part you live in. Do you live in shared accommodation? If the only part youshare is a hall or staircase, or a communal room in shelteredaccommodation, say No. How many living rooms do you have? How many bedrooms do you have? How many bedsit rooms do you have? 1 1 1 1 Mr. NathaponWongtreenatrkoon upper maisonette 6 Arundel Terrace Brighton BN2 1GA No No No 18/04/2015 18/04/2015 Yes 17/04/2016 assured shorthold unfurnishedHow many bathrooms or shower rooms do you have? How many separate toilets do you have? How many kitchens do you have? How many other rooms do you have? What is your landlord's full name and business address? Enterthe postcode with a space so it matches the format A1 1AA. If your landlord isn't the owner of the property but manages itfor someone else, please give the owner's details here. Name of Landlord Flat number/name House number/name Street name Town or city Postcode Does your landlord have an agent? By agent we mean theperson or organisation you actually pay rent to. If you pay rentdirectly to your landlord please answer No. Did you know your landlord or agent before you moved into theproperty? Are you, or any of your children related to your landlord oragent, or to your landlord's partner or the agent's partner?Related includes related through marriage, even if themarriage has ended. When did you move into your home? (Enter year in the formatYYYY) When did your tenancy start? (Enter year in the format YYYY) Do you know when your current tenancy is due to end or berenewed? When is your current tenancy due to end or be renewed?(Enter year in the format YYYY) What sort of tenancy do you have? Is the property rented out as furnished, unfurnished or part-furnished? No No No No No No every calendar month 1150 No you (and other jointtenants, if there areany) Brighton & Hove No Council Tax band C

No No NoSection D : Rent and Council TaxDo you own another property in the United Kingdom orabroad? Has your rent been registered as a fair rent by a rent officer? Do you require a non-resident carer to stay over night in yourhome? Are you an approved foster carer? Do you have a bedroom kept for someone who usually liveswith you, but is currently away serving with the Armed Forces? Are you living in shared accommodation? Only answer Yes ifyou are sharing your house with other adults and if you onlyhave exclusive use of a single room e.g. a bedroom foryourself and your partner (if you have one). If you haveexclusive use of two rooms or more, then answer No. How often is your rent due? How much rent is due in this period? Do you get any rent-free weeks? Who is responsible for the Council Tax for your home? Please choose the parish you live in, we need to know this tocalculate the Council Tax for your home. If you do not know,please look at your Council Tax bill or contact the Council TaxDepartment.. Does your Council Tax bill have a Disabled Reduction(awarded because a room in your house has a specific use fora disabled person)? Which Council Tax band is the home you are claiming for in? What is your Council Tax reference number? Are you behind with your rent? Has your rent changed in the last 12 months? Do you know when your next rent increase is due? Section E : Health and Disability none No No No No No No No No NoBenefits for disability or ill health.Which of the following benefits or allowances (if any) do youget because you have a disability, or because ill health or injurymeans you cannot work?Disability Living Allowance (including any payment to MotabilityFund)Personal Independence Payment or Armed Forces IndependencePaymentAttendance AllowanceIncapacity BenefitSevere Disablement AllowanceDisabled Student AllowanceIndustrial Injuries Disablement BenefitWar Disablement PensionPrivate Car Allowancenone Are you registered blind (or been registered blind within theprevious six months)? In the last eight weeks have you received Carer's Allowancefor looking after a person with a disability? Are you entitled to Carer's Allowance but not getting it? Do you provide care or support (either paid or unpaid) foranother person who is NOT your dependant child under 18,nor your partner? Are you in hospital at the moment? Are you severely mentally impaired? Section F : ChildrenDo you live with any dependant children? Section G : Other AdultsDo any other adults live in your home? Is there anyone who usually lives in your home, but is not livingthere at the moment because they are in legal custody (suchas in prison, on remand, youth offenders centre)? Section H : Employment self-employed (even ifyou are off sick or onmaternity/paternity oradoption leave) working 30 other self-employed Music andEntertainment. 07/01/2014 Yes No Yes 3500 3600 0.00 0.00 0.00 No No None NoWhat is your main work situation? What is your current situation in this job? How many hours do you work in this job each week? If thenumber of hours you work varies from week to week, put anaverage figure. Include hours worked as overtime. Are you a childminder, taxi-driver or self-employed in anotherway? What kind of self-employed work is this? When did this business start? (Enter year in the format YYYY) Is the business address the same as the address that you areclaiming for? Do you have any partners in this business? Have you been self-employed in this business for at least 12months? What was your gross income in this business over this period? What were your approved expenses in this business over thisperiod? How much income tax did you/will you pay from this businessto cover this period? How much did you/ will you pay as national insurancecontributions from this business to cover this period? How much did you/will you pay in pension contributions fromthis business over this period (if none put 0)? Do you currently get a Business Start-Up Allowance for thisbusiness? Do you have any other jobs or self-employment, or a trainingallowance you have not already mentioned? Are you treated as not being in full-time paid employment? Do you do any work, unpaid or paid, that you have notmentioned already, (including voluntary work)? No No No No No No No Working Tax Credit Every four weeks 213.48 No Yes Yes none NoSection I : Pensions, Benefits and Tax CreditsDo you get Universal Credit? Do you get Income Support ? Do you get income based Jobseeker's Allowance (JSA)? Do you get income-related Employment and SupportAllowance? Do you get contributory Employment and SupportAllowance? Have you made a claim for Universal Credit and are waiting tohear about the claim? Have you made a claim for Income Support, income-basedJobseeker's Allowance, income-related Employment andSupport Allowance or Pension Credit, and are waiting to hearabout the claim? Do you get a Tax Credit? Tax credit can be paid as Child Tax Credit or Working TaxCredit, or both. Which one(s) do you get? Working Tax Credit . How often do you get this tax credit? How much Working Tax Credit do you get in this period? Does this include an amount for a disability you may have? Does your Working Tax Credit award letter say that you work30 hours a week or more? Is your Working Tax Credit paid into a bank account? Do you get any pensions? Which of the following pensions (ifany) do you get?Retirement Pension (state pension)Occupational pension (from an organisation you used to work for)Private pension - including a pension from abroadWar Widow's/Widower's Pension (sometimes called a WarPension)Widow's or Widower's Pension/BenefitIndustrial Death Benefit/Pensionnone Have you put off drawing all or part of a personal or privatepension? None None No No NoBenefits for family circumstances Which of the following benefits (if any) do you get?Maternity Allowance (paid by the Department for Work andPensions (DWP) - not from work)Widowed Parent's Allowance (sometimes called Widowed Mother'sAllowance)Bereavement AllowanceFostering AllowanceNone Work-related benefits Which of the following benefits or credits (if any) do you get?Contributory Jobseeker's Allowance (not Income-based)Reduced Earnings AllowanceIn Work CreditNone Have you made a claim for any other benefits, pensions,allowances or tax credits; but are not getting them becauseyou are still waiting to hear about the claim? Section J : Money Owed to YouDoes anyone owe money to you? Are you expecting to get any other money in the next 12months? Section K : Savings a bank account(s) 1 Lloyds Mr Jackson Baird 309741 10449468 0.53 noneWhich of the following accounts, savings or investments (ifany) do you have? You still need to tell us if the account doesnot have anything in it or is overdrawn.a bank account(s)a building society account(s)a post office account(s)premium bondsISAsunit trusts, PEPs, or TESSAsincome bonds or capital bondsmoney or property held in trustnational savings certificatessharesany other savings or investmentsnone Previously you said you had a bank account. How many bankaccounts do you have? The first bank account What is the name of the bank? What is the name of the account holder? What is your sort code? What is your bank account number? How much money is in this bank account? If overdrawn, or inthe red, please put a negative amount. Do the accounts, savings or investments you have told usabout include money from any of the following?payment from a charityFar Eastern Prisoner of War CompensationCompensation to Victims of the Second World War Atrocitiesarrears (money owed to you) of certain benefits and specialpayments received in the last 12 months - see help aboveproceeds from selling a property within the last six months, if youare going to use that money to buy another homea lump-sum payment of state pension (retirement pension) paidbecause you put off taking the pension for at least 12 monthsspecial payment for variant Creutzfeldt-Jakob disease (CJD)sufferers and their familiesnone Section L : Money Coming In No No No No

No No I am making the claim Do you get any maintenance payments or child support, froman ex-partner (or ex-partners) - include any money that goesdirectly to your child(ren)? Do you have any other money coming in that you have notalready mentioned. If you have money from more than one source, please put yourmain source first - we will ask about others later. Do notinclude money from the Macfarlane Trusts, the Fund, theEileen Trust, the Independent Living Funds, the Skipton Fund,the Caxton Foundation or MEFT Ltd. Section M : Money Going OutDo you pay any money to contribute to the expenses of a childwho is a student in advanced education such as university? Do you pay any money into a personal (private) pensionscheme (other than through work)? Section N : Other InformationIf you think there is anything else to tell us about that you havenot already covered, tell us below. This could include details ofany other income or property that you have. Do you agree that Brighton & Hove Council can shareinformation about the progress of your claim with the personwho helps you? Do you agree that Brighton & Hove Council can shareinformation about the progress of your claim with yourlandlord? Are you the person making this claim, or have you answeredthe questions on behalf of the person making the claim? White : British I would like anybenefit paid directly tomyself Yes Mr Jackson Baird Lloyds 309741What is your ethnicity?Asian or Asian-British : IndianAsian or Asian-British : PakistaniAsian or Asian-British : BangladeshiAsian or Asian-British : Any other Asian BackgroundBlack or Black-British : CaribbeanBlack or Black-British : AfricanBlack or Black-British : Any other Black BackgroundChineseOther EthnicityMixed : White and Black CaribbeanMixed : White and Black AfricanMixed : White and AsianMixed : Any other mixed BackgroundWhite : BritishWhite : IrishWhite : Any other White BackgroundArabGypsy/TravellerI do not wish to disclose this information Section O : Getting Your BenefitsIt is possible to have your benefit paid directly to your landlord,but only ifyou currently owe your landlord 8 weeks or more in rentarrears then we are required to pay your benefit directlyto your landlord.you have difficulty managing your finances, benefit canthen be paid directly to your landlordPlease choose one of the options belowI would like any benefit paid directly to myselfI would like any benefit paid directly to my landlord as I am in rentarrears of 8 weeks or moreI would like any benefit paid directly to my landlord as I havedifficulty managing my finances Do you have a bank account currently? What name or names is the account in? What is the full name of bank or building society you want theHousing Benefit paid into? Branch sort code 10449468

38 Blue Boar Row,Salisbury SP1 1DB NoAccount number Only answer this question if this is a building society account. What is the building society roll number or reference number?If none, leave blank What is the address of the bank or building society? Do you want to backdate your claim for benefit? Changes you must tell us aboutTell us straightaway if:You stop receiving Income Support, Job Seekers Allowance, Incapacity Benefit orEmployment and Support Allowance;Your Working Tax Credit or Child Tax Credit changes;You move (even if you only move to a different room or flat within the same property);A child leaves school or leaves home;You have a baby;Your child starts to be cared for, or stops being cared for, by a registered childminder, ornursery or playgroup;Someone moves into or out of your home (including boarders and sub-tenants);Your income, or the income of anyone living with you, goes up or down;You or anyone living with you becomes a student, or takes up a Government TrainingScheme;You or anyone living with you goes into hospital or a nursing home, or goes into prison (evenif this is on remand);You or anyone living with you gets a job, or changes their job, or becomes unemployed;You or anyone living with you takes more than one job;You return to work after a period of illness where you have been receiving benefit;You or anyone living with you has a change in capital or savings of 150 or more. This doesnot apply to people receiving Income Support, Job Seekers Allowance (Income Based) orPension Credit (Guarantee Credit) - please note you should notify the DWP;Your rent changes;You and/or your partner will be away from home for 2 weeks or more. Where possible, tell usabout this BEFORE you go;You receive a decision from the Home Office;Someone starts to receive Carer's Allowance for looking after you;If you change the bank account that we are paying your Housing Benefit into;If you inherit a property or any money from a will.;ANYTHING AT ALL which is different from what you have told us on this claim form;If you don't tell us about these changes you may lose money you are entitled to or you may get toomuch benefit.You must make sure that you tell us about these changes. Don't rely on someone else to pass themessage on. It is an offence not to tell us about any change of circumstance that affects yourbenefit.Evidence we needWe must see proof of certain things before we accept your claim. Here is a list of the documentswe need. You must send the originals - not photocopies. You can post the documents to us - but ifyou are sending valuable original documents, you may prefer to take the documents to the counciloffices who will handle the application for you and give your documents back (see 'What to donext' below).Evidence of Personal DetailsEvidence of your identityPlease provide one document from the list below:Birth or Marriage certificate.Birth certificate, Divorce, annulment or separation papers in your current name. If your namehas changed because of marriage, provide your marriage certificate as well.Full or provisional driving licence (photo card or paper).Passport (current and valid) or national identity card.Residence permit, alien's registration certificate, Immigration and National Directorate traveldocument, standard acknowledgement letter (SAL 1or2) or Application Registration Card(ARC).Gas, electricity, phone or water bill in your name, received within the last three months (butnot a mobile phone bill).Medical card or television licence in your name.National Insurance number card (not handwritten).Bank Statements (recent).Evidence of your National Insurance numberPlease provide one document from the list below. It must be a different document to the oneprovided as proof of identity (see above):P45 or P60.Payslip, salary statement or works pension statement (as long as it shows your NINo).Letter from Inland Revenue about tax or tax credit.Letter that the Pension Service or Jobcentre Plus has sent to you (not handwritten).National Insurance number card (not handwritten).Evidence of Your RentEvidence of your rentPlease Provide:your tenancy agreement; oryour rent book; ora signed, detailed statement from your landlord.All of the above must include your landlord's name and address.Evidence of EmploymentEvidence of your Self EmploymentPlease Provide:your most recent certified accountsIf you have only recently started your business, or if you do not have an accounts please go towww.brighton-hove.gov.uk/hbselfemployed for guidance on what to submit.Evidence of Bank Accounts, Savings and Other FinancesEvidence of bank accountsIf your total capital is less than 6000 you do not need to provide bank statements as evidence ofyour capital, however we may ask for them elsewhere as evidence in support of income receivedor payments of rent made. This will be clearly requested on this sheet if it is the case.If your total capital is 6000 or more please provide:the last two bank statements - they must show the last two month's transactions (mini-statements or balance slips are not acceptable); ora letter from the bank describing the type of account, the balance outstanding, anytransactions in the last two months, and the account numberPlease provide these documents within three days so your claim can be assessed as soon aspossible. You have an absolute maximum of one calendar month to provide these documents, ifyou do not provide them within this time it will be assumed you do not qualify for benefit.What to do nextYou must provide the evidence requested on this sheet. You can post it or you can bring theevidence to us. Do not send valuable items such as benefit order books, bank books or passportsin the post. Bring them to the customer service centre at Bartholomew House, BartholomewSquare, Brighton, BN1 1JP between 8.45am and 4.30pm. The member of staff you see willnormally deal with your claim.You should get the evidence to us within the next three days so your claim can be assessedstraight away. You have an absolute maximum of a month to provide this but any delay will lead toyour payment taking longer. If you cannot get the evidence within 2 weeks, let us know. We maybe able to help you.How we will pay youWe will tell you if you can get benefit, and how much, as soon as possible. If you qualify forbenefits, here's how it will be paid:Housing Benefitif you are paid directly, payment will be made every 2 weeksif your benefit is paid to your landlord, payment will be made every 4 weeksCouncil Tax ReductionWe pay your benefit straight into your Council Tax account - not to you. This means that you haveto pay less council tax, or no council tax at all. We will send you a bill showing how much counciltax to pay.How we collect and use informationThe Council collects information for Housing Benefit and Council Tax Reduction purposes, but itmay be used for any of the Council's purposes. We may check information that you provide or thata third party provides about you, with the other information we hold.We may also get information about you from certain third parties, or give information to them tocheck the accuracy of information, to prevent or detect crime, or to protect public funds in otherways as permitted by law. These third parties include government departments and localauthorities. We will not disclose information about you to anyone else outside the Council unlessthe law or permits us to. The Council is registered under the Data Protection Act 1998 for thesepurposes and is the Data Controller. If you want to know more about what information we haveabout you or the way we use this information please write to the Council's Data Protection Officer,Kings House, Grand Avenue, Hove.Who we areHousing Benefits, Brighton and Hove City Council, Bartholomew House, Bartholomew Square,Brighton, BN1 1JPCouncil Tax ReductionWhen you claim Council Tax Reduction, we may use your details to make you liable for CouncilTax at your address and to make sure you get the correct Council Tax discount.