This Form was created in Word using VF Creator.Created: 22/11/2017 by the VF Creator team.

VF Creator turns documents created in Word into online forms.

You can view/edit eForm features, after installing the VF Creator add-in. A new VF Creator ribbon will be available which allows you to create/edit eForms.

Please visit VictoriaForms.com /VF-Creator/ to start creating online forms in Word.

Financial Assessment FormCare, Housing Support Services and Residential/Nursing Home Care

Personal Details Framework No

1. Service User 2. Your Spouse/partner/civil partner Title (Mr, Mrs, Miss, Ms, other) Title (Mr, Mrs, Miss, Ms other)

First Names First Names

Surname Surname

Date of Birth Date of Birth

Address Address

Postcode Postcode National Insurance Number National Insurance Number

Day time telephone number Day time telephone number

Care, Housing Support Services and Residential/Nursing Home CarePlease tick this box if you do not wish to provide your financial information

Or your capital is over the capital limit.

The amount of the capital limit is included in the accompanying letter.

In doing so, you accept that you will be expected to contribute to the full cost of your chargeable service(s) for Care, Housing Support Services and Residential/Nursing Home Care. If someone else deals with your financial affairs, please complete page 2 for our records. Sign the declaration on page 8.

If your circumstances change you must notify us as soon as possible. This may affect your charge.

We will ask you to give us proof of your income, outgoings and savings. For example copies of your bank or building society statements or books, benefit letters or books and payslips. We will use the information you give us to work out the assessed amount you can contribute each week towards the cost of the care or support that you receive. Photocopies of documents are acceptable. (Any originals provided will be returned) Failure to provide this information may result in you being charged the full cost of your care package.

Correspondence

Who should we send all correspondence to if not you?

Person to receive correspondenceTitle (Mr, Mrs, Miss, Ms other)

First Names

Surname

Date of Birth

Address

Postcode Day time telephone number

Relationship

Please tick (✔) one of the following boxes to show who you are in relation to details aboveHolder of Power of AttorneyAppointee or Agent for DWP BenefitsOther (please specify)

Additional Notes

Where you Live

1. Do you own your own home? Yes Go to question 2No

Go to question 113. Does your spouse/partner still live in the property? Yes

Continue on to Benefit Health Check

No Go to question 34. What is the approximate value of your house?

5. Are there any debts secured on your property? Yes Go to question 5

No Go to question 66. Please state the value of debts secured against the property.

7. Is your property jointly owned? Yes Go to question 7 No

Go to question 8

8. Please state the joint owners

9. Does anyone currently live with you? (i.e. brother, sister, son daughter?)

Yes Go to question 9 No Go to Benefit Health Check

10. Are they incapacitated in any way or are they over 60 years of age?

Yes Go to question 10

No Go to question 1111. Please describe disability or state their age?12. Have you previously owned a property which you have sold,

transferred or given away? Yes Go to question 12

No Go to Benefit Health Check14. Please state if the property was sold, transferred or gifted

15. Please give details of the month, year and the value of the sale/transfer or gift.

16. What is the address of the property?

Please note that information regarding any property you live in now or used to own may be verified by Land Registry.

Benefit Health CheckMany people do not realise that they may be entitled to extra money from DWP (Department for Work and Pensions) if they have an illness or disability, these benefits are often paid on top of your existing income and may not affect what you already get.Please tick (✔) the following box if you wish a benefit health check to be carried out. We will check your records and if you may be entitled to any extra money, we will contact you to discuss.

Benefit Health Check

Residential Care & Benefits Please be aware that moving into a care home may also affect your Attendance Allowance (AA), Disability Living Allowance (DLA) or Personal Independence Payments (PIP). You should contact the Department for Work and Pensions to advise you are now in residential care. Telephone numbers for the DWP can be found on the final page.

If you receive financial help from the social work service to pay the care home fees, including any assessed entitlement to free personal care, your AA/PIP/DLA will stop after 4 weeks.(Those who receive care in their own homes will continue to be entitled to these benefits)

Income

Please tick this box if you are in receipt of Independent Living Fund Award.

Do you have a partner living with you? Please tick (✔) box Yes No

Is your partner in receipt of Pension Credit or Savings Credit? Yes No

We only require your partner’s full financial information if care at home is being provided to both of you or if you are in receipt of housing support services.Benefits marked with a * can be checked and confirmed by the Financial Assessment Team. Please tick here if you want us to confirm

your benefit rates

YOU

AMOUNT

How often Office Use Only

YOUR PARTNER

AMOUNT

How often Office Use Only

State Retirement Pension*

Pension Credit [Guarantee Credit]*Pension Credit [Savings Credit]*

Income Support*

Attendance Allowance*

Disability Living Allowance (Care component)*Personal Independence Payment (daily living component)*Severe Disability Allowance*Universal Credit*

Working Tax Credit*

Employment and Support Allowance ESA*Industrial Injury Benefit*

Occupational/Private PensionWar Widow’s Pension

Statutory Sick Pay

Net Earned Income

Income from rent/lease of propertyAny other income please state

Total Total

Bank Accounts, Savings and Investments

Please provide details of any bank/post office or building society accounts below which you hold solely or in joint names. This includes the accounts which any benefits are paid into. If you do not have any accounts, we require verification of where your income is paid into.

Please include copies of your bank statements for all accounts.

Please note for clients going into residential care for respite/temporary/long term care only complete column ‘YOU’

Bank/Building Society/Post Office Savings/Current Accounts including Tessa & ISA’s & PEP’s

Amounts Type of Account You Your Partner

For joint accounts split savings between you and your partner

Stocks, Shares and other Investments

Current Value Details You Your Partner

For joint holdings split value between you and your partner You Your Partner

Premium Bonds National Savings Certificate Investment Bonds

Please provide all relevant documents as evidence. We will accept photocopies. Please continue on a separate sheet if necessary and attach it to the form. (Any original documents provided will be sent back)

Other Capital

Current Value Details Annuities Ownership of Buildings Ownership of Land

Trust Fund Income Any Capital held abroad Any Capital held by Accountant/Solicitor

Money You Pay Out (Allowable Expenditure)

Expenditure Amount

How Often e.g. monthly 4 weekly

Actual Rent Payment – rent element only, not including service charges or any other charges from landlord

Actual Rent Payment – rent element only, not including service charges or any other charges from landlordAre you in receipt of Housing Benefit? Yes No (If yes, how much?)Mortgage(Payable by you on your main residence only) Actual Council Tax (including Water Rates) Payment – amount shownShould be reduced by any Council Tax Reduction received (Payable by you on your main residence only)

If you are receiving respite or temporary care in a Care Home, please also complete section below:These allowances listed below are the only costs, which can be allowed to maintain a household when respite care is being provided.

We are only able to allow minimum charges for Gas, Electricity and Telephone.

Please show sums, which are applicable to the applicant only.

If you simply make a contribution to your household, please show the sum you give – we may be able to allow only some of this

£ Weekly

Weekly Gas Costs Weekly Electricity Costs Weekly Telephone Costs Weekly House Insurance Costs Weekly Care Call Weekly TV Licence Weekly Sheltered Accommodation Charge Weekly Other (please state) Weekly

WeeklyWeeklyWeeklyWeeklyWeeklyWeeklyWeekly

Weekly

Disability related expenses

Customers must be in receipt of Attendance Allowance, Disability Living Allowance (DLA) or Personal Independence Payments (PIP) before using this section. If you do not receive a disability related benefit such as these but feel you should, please contact us and we can help you apply. If the total cost of what you pay out due to your disability is more than £10 per week, you will need to tell us what these are and send us proof of these expenses as listed below. If you think these costs are under £10 you do not need to provide any further details if they are identified in your care needs assessment.

Do you have expenses that are related to your illness or disability? Yes No

Disability related expense Proof required if more than £10

Cost and how often you pay (weekly/ monthly/ annual)

Do you think you pay higherThan average for the cost of your heating?

Yes No Last 2 electricityand gas bills

Cost £

Frequency

Do you have medical problems that need a special diet? Yes No

Purchase receipts covering an eight week period

Cost £

Frequency

Do you receive any care that we do not provide (eg private cleaner or privately arranged carer?)

Yes No Receipts covering a four week period

Cost £

Frequency

Do you have exceptional mobility needs that are not covered by the mobility part of DLA or PIP?

Yes NoPurchase receipts covering a four week period

Cost £

Frequency

Do you have any extra laundry or cleaning costs due to your disability?

Yes NoReceipts covering a four week period

Cost £

Frequency

Do you feel that you have any other costs that are caused by your illness or disability or that help you to live independently? Yes NoIf so please detail

Receipts covering a four week period Cost £Frequency

Receipts covering a four week period Cost £Frequency

Receipts covering a four week period Cost £Frequency

Receipts covering a four week period Cost £Frequency

DeclarationI declare that the information I have given is true and complete to the best of my knowledge and belief. I grant permission for you to obtain verification of my declared income and savings if required.

I agree to pay the charge assessed by Dumfries and Galloway Council, and to pay any backdated amount should I be awarded a relevant benefit retrospectively.

I understand that legal action may be taken against me if I give information, which is fraudulent or incomplete and that a readjustment of charges will be carried out using the correct information when it becomes available. Charges will be backdated to the date the change occurred.

I also declare that I will notify you if there is any change in my financial circumstances.

This authority is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes. For further information see http://www.councilname.gov.uk/fairprocessing.

Name Signature Date

Partner

Name Signature Date

If you have assisted in the completion of this form please show your details below:

Name Signature Date Address

Telephone number Please state relationship to Service user

Please tick (✓) one of the following boxes to show who you are:Holder of Power of Attorney*Guardian – Office of Public GuardianAppointee or Agent for DWP BenefitsNext of KinOther (Please specify)

* You will need to provide a copy of Power of Attorney DocumentAttendance Allowance 0345 605 6055Disability Living Allowance 0345 712 3456

For help or enquiries: Call 030 33 33 3008 Personal Independence Allowance 0345 850 3322Email FATEAM@councilname.gov.uk