*By 'Couple' we mean anyone who you are married to, or in a civil partnership with, or live with as if you are married or civil partners.
Are you or your partner registered blind?
No
Yes
Do you live permanently in a Care Home?
No
Yes
Do you or your partner get Attendance Allowance or the care component of Disability Living Allowance?
No
Yes (One of us)
Yes (Both of us)
How many children aged under 16 do you have?
0
1
2
3
4
5
6
7
8
9
10
How many children aged between 16 and under 20 do you receive Child Benefit for?
0
1
2
3
4
5
6
7
8
9
10
Do you have any children who are registered blind or receive Disability Living Allowance?, if yes how many?
No
1
2
3
4
5
6
7
8
9
10
Are you or your partner entitled to Carer's Allowance?
No
Yes (One of us)
Yes (Both of us)
Does anyone get Carer's Allowance for looking after you?
No
Yes
Have you had a continuous HB/CTR claim since April 2016?
No
Yes
Are you (or your partner) receiving one of the following:
No
Yes
Are you (or your partner) receiving any of the following:And have no one aged 18 and over (other than your partner) living with youAnd no-one is receiving Invalid Care Allowance / Carers Allowance in respect of you (or your partner)
No
Yes
Does the above apply to both you and your partner?
No
Yes
Are you or your partner receiving the Guarantee Credit component of Pension Credit?
No
Yes
Are you or your partner receiving Income Support, Jobseeker's Allowance (Income Based) or Employment & Support Allowance (Income Related) ?
No
Yes
What are your, and your partners (if applicable), total working hours per week?
Less than 16 hours per week
Less than 30 hours per week
More than 30 hours per week
Net wage = Your Wage minus Tax, National Insurance and 50% of any private pension payment
Unearned Income (please enter the gross weekly amount you get)
Please note: If your Local Authority does not operate a local scheme to disregard War Widow's Pension or War Disablement Pension in full, then these incomes should be entered as 'Any Other Income' minus your Local Authority’s relevant disregard.
Child Benefit (disregarded)
Disability Living Allowance
Employment & Support Allowance (ESA)
Industrial Disablement or Injuries Pension
Jobseekers' Allowance (Contribution Based)
Child Maintenance Received (disregarded)
Private Pension / Works Pension
Severe Disablement Allowance
War Disablement Pension (disregarded)
War Widows Pension (disregarded)
Savings Credit component of Pension Credit
Savings
Do you or your partner have any savings?
Investment or Income Bonds
National Savings certificate
Personal Equity Plan (PEPs)
Money You Pay Out
(please enter the amount you pay per week)
Parental contribution towards a child's student maintenance grant
Payments towards a private pension scheme which is not deducted from your wage
Payments to a registered childminder to look
If you rent your property from a private landlord, enter the Local Housing Allowance (LHA) rate for the number of bedrooms you need. For more information, visit the gov.uk LHA calculator . If you do not rent from a private landlord enter your net rent per week? (Net of ineligible services)
If you rent your property from a private landlord, enter the Local Housing Allowance rate for the number of bedrooms you need. If you do not rent from a private landlord enter your net rent per week? (Net of ineligible services)
If you rent from a social landlord and you have too many bedrooms your benefit may be reduced. For more information, visit the gov.uk website .
Does the above amount include any discounts?
No
Yes
Do you have anyone else (other than your partner) living with you?
No
Yes
Please enter how many people live with you for each category
A couple only attract one non-dependant deduction.
If you have 2 non-dependants who live together as a couple,
enter only one non-dependant
deduction,
determined by adding together their total combined gross income
, in the relevant category.
Aged under 18, whatever their income
0
1
2
3
4
5
6
7
8
9
10
Aged under 25, getting Income Support, Jobseeker's Allowance (Income Based), Employment & Support Allowance (Income Related - Assessment Phase), OR in receipt of Pension Credit
0
1
2
3
4
5
6
7
8
9
10
Aged 25 and over, getting Income Support, Jobseeker's Allowance (Income Based), Employment & Support Allowance (Income Related)
0
1
2
3
4
5
6
7
8
9
10
In Full Time work earning over £451.00 per week (gross)
0
1
2
3
4
5
6
7
8
9
10
In Full Time work earning between £363.00 and £450.99 per week (gross)
0
1
2
3
4
5
6
7
8
9
10
In Full Time work earning between £272.00 and £362.99 per week (gross)
0
1
2
3
4
5
6
7
8
9
10
In Full Time work earning between £209.00 and £271.99 per week (gross)
0
1
2
3
4
5
6
7
8
9
10
In Full Time work earning between £143.00 and £208.99 per week (gross)
0
1
2
3
4
5
6
7
8
9
10
Not in Full Time work, OR in Full Time work earning less than £143.00 (gross)
0
1
2
3
4
5
6
7
8
9
10
Lodger
0
1
2
3
4
5
6
7
8
9
10
Currently in Prison
0
1
2
3
4
5
6
7
8
9
10
On a Youth Training Scheme
0
1
2
3
4
5
6
7
8
9
10
Students
0
1
2
3
4
5
6
7
8
9
10
Submit
