Information

  • Rent account number

  • Tenancy start date

  • Property type

  • Floor level of the property

  • Number of bedrooms

  • Tenants name

  • Conducted on

  • Location

Persons resident

  • Tenant name:

  • Tenant Date of Birth

  • Working / Claiming Benefit?

  • Please enter employers name

  • Please enter income

  • Please select benefit

  • Are there other persons living in the household?

  • Add each person
  • Persons name

  • Date of Birth

  • Working / Claiming Benefit?

  • Please enter employers name

  • Please enter income

  • Please select benefit

  • Relationship to tenant?

  • Please enter relationship

Arrears details

Arrears details

  • Arrears balance

  • Gross rent

  • HB entitlement

  • Net rent

  • Latest Arrears Action

  • Are you in receipt of Housing Benefit?

  • Why has HB not been applied for?

  • Reason For Rent Arrears?

  • Has a Income & Expenditure form been completed?

  • Why Not?

  • Has a referral been made to Welfare Benefits Team?

  • Why not? (If referral refused, please state reason)

Awareness of available support

  • Has the tenant(s) been made aware of money advice services? (Citizens Advice, Shelter, The Money Advice Service, Step Change)

  • Please provide details of any support the customer is currently receiving:

  • Does the tenant(s) have any health problems? (please provide details)

Agreement and Declaration

Agreement

  • Please enter the amount of the repayments to be paid in addition to the weekly rent.

  • Please enter the frequency of the payments

Authorisation & Declaration

  • I confirm the information given is correct and I agree to pay my weekly rent in addition to the above amount and at the above frequency until my arrears are clear, as agreed.

  • I / We also authorise Medway Council to make any enquiries / act on my behalf with reference to my rent arrears / housing matters, both now and in the future.
    I understand that this may involve them sharing my information and receiving information with other agencies - Various Council departments (including Housing Benefit and Social Services), DWP, Citizen Advice Bureau, Police and NHS Healthcare.

  • Tenants signature:

  • Joint tenant:

  • Signed on behalf of Medway Council:

  • Job title:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.