Arrears visit report

• Rent account number

• Tenancy start date

  Date

• Property type

  House

  Flat

  Bungalow

• Floor level of the property

  1

  2

  3

  4+

• Number of bedrooms

  1

  2

  3

  4+

• Tenants name

• Conducted on

  Date
• Location
  Address

Persons resident

• Tenant name:

• Tenant Date of Birth

  Date

• Working / Claiming Benefit?

  Working

  Claiming Benefit

• Please enter employers name

• Please enter income

• Please select benefit

  Select Income Support Income Based Job Seekers Allowance Contribution Based Job Seekers Allowance Contribution based ESA Income related ESA Incapacity Benefit Maternity Allowance Bereavement Benefit Industrial Injuries Benefit

  • Income Support
  • Income Based Job Seekers Allowance
  • Contribution Based Job Seekers Allowance
  • Contribution based ESA
  • Income related ESA
  • Incapacity Benefit
  • Maternity Allowance
  • Bereavement Benefit
  • Industrial Injuries Benefit

• Are there other persons living in the household?

Add each person

• Persons name

• Date of Birth

  Date

• Working / Claiming Benefit?

  Working

  Claiming Benefit

• Please enter employers name

• Please enter income

• Please select benefit

  Select Income Support Income Based Job Seekers Allowance Contribution Based Job Seekers Allowance Contribution based ESA Income related ESA Incapacity Benefit Maternity Allowance Bereavement Benefit Industrial Injuries Benefit

  • Income Support
  • Income Based Job Seekers Allowance
  • Contribution Based Job Seekers Allowance
  • Contribution based ESA
  • Income related ESA
  • Incapacity Benefit
  • Maternity Allowance
  • Bereavement Benefit
  • Industrial Injuries Benefit

• Relationship to tenant?

  Joint tenant

  Partner

  Son / Daughter

  Other

• Please enter relationship

Arrears details

• Arrears balance

• Gross rent

• HB entitlement

• Net rent

• Latest Arrears Action

  Select Letter 1 or 2 NOSP Prompting Court Court Action Breach of Order Stay

  • Letter 1 or 2
  • NOSP
  • Prompting Court
  • Court Action
  • Breach of Order
  • Stay

• Are you in receipt of Housing Benefit?

  Yes

  No

• Why has HB not been applied for?

• Reason For Rent Arrears?

• Has a Income & Expenditure form been completed?

  Yes

  No

• Why Not?

• Has a referral been made to Welfare Benefits Team?

  Yes

  No

• 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)

  Yes

  No

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

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

Agreement

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

• Please enter the frequency of the payments

  Weekly

  Fortnightly

  Four weekly

  Calendar monthly

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:

  Sign

• Joint tenant:

  Sign

• Signed on behalf of Medway Council:

  Sign

• Job title: