DFG Application Form - Benefits

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Part 1 - Application Details - This must be the owner or tenant of the property where the work is proposed

• Title

• First name(s)

• Last name

• Applicants Address
  Address

• Contact Details for applicant

Details of person who the proposed works are for - relevant person

• Name (if different from above)

• Address where works are to be carried out (if different from above)
  Address

• Contact details (if different from above)

• Date of birth

  Date

• National Insurance Number

• Brief details of medical conditions of the disabled person

• Would you prefer us to contact a family member or friend on your behalf?

  Yes

  No

• Name of family member or friend

• Relationship to applicant

• Contact Details

• Is this property...

  House / bungalow

  Flat

  Mobile home

  Other

• Are you...

  A tenant of a private landlord

  A tenant of a social landlord

  An owner / occupier

  Owner

• Name of your Landlord

• Address of your Landlord
  Address

• Name of your Landlord

• Address of your Landlord
  Address

• Please list the names and dates of birth of all occupants of the property to be adapted

• What works have been recommended by your Occupational Therapist

• Have you started the works

  Yes

  No

• Have you completed the works

  Yes

  No

• Have you applied for planning permission for the works

  Yes

  No

• What is the Planning reference number

• What was the date the application was made

  Date

• What was the outcome of the application if already decided

• Have you applied for building regulation approval for the works

  Yes

  No

• What is the Building Control reference number

• When was the Building Control application submitted

  Date

• What was the outcome of the application if already decided

• Will a member of your family carry out the works? (By a member of your family we mean a partner or blood related relative

  Yes

  No

• Do you agree for any grant approved to be paid to the contractor directly

  Yes

  No

• Do you or your partner receive Universal Credit

  Yes

  No

• Do you or your partner receive Income Support

  Yes

  No

• Do you or your partner receive Income related Employment and Support Allowance (not contribution based of ESA alone)

  Yes

  No

• Do you or your partner receive Income based Jobseeker's Allowance (not contribution based on JSA alone)

  Yes

  No

• Do you or your partner receive Guarantee Pension Credit (not Savings Pension Credit alone)

  Yes

  No

• Do you or your partner receive Working Tax Credit and/or Child Tax Credit (where your annual income for the purposes of the tax credits assessment was below £15,050)

  Yes

  No

• Do you or your partner receive Housing Benefit

  Yes

  No

• If you have ticked any of the boxes above you will need to provide evidence of your benefit award and you will qualify for a mandatory disabled facilities grant without the need for a means test

  Agree

  Do not agree

• Please tick only one of the following:

  Select I am the applicant and the disabled person for whose benefit the works are being done, and I confirm that it is my intention to remain living in this property which is the subject of this application for 5 years. I am the partner of the applicant/disabled person for whose benefit the works are being done, and I confirm that it is his/her intention to remain living in this property which is subject to this application for 5 years. I am the applicant and the parent or guardian of a disabled child or young person and I confirm that it is my intention that he/she will remain living in this property which is subject to this application for 5 years I am another person who has a legal power to act on behalf of the applicant/disabled person (e.g. power of attorney) and I confirm that it is his/her intention that he/she will remain living in this property which is subject to this application for 5 years

  • I am the applicant and the disabled person for whose benefit the works are being done, and I confirm that it is my intention to remain living in this property which is the subject of this application for 5 years.
  • I am the partner of the applicant/disabled person for whose benefit the works are being done, and I confirm that it is his/her intention to remain living in this property which is subject to this application for 5 years.
  • I am the applicant and the parent or guardian of a disabled child or young person and I confirm that it is my intention that he/she will remain living in this property which is subject to this application for 5 years
  • I am another person who has a legal power to act on behalf of the applicant/disabled person (e.g. power of attorney) and I confirm that it is his/her intention that he/she will remain living in this property which is subject to this application for 5 years

• Name

• Signature

  Sign

• HB/CTS Reference Number

• Date

  Date