Council Tax disability relief

Your details

Your first name

Your last name

Your address

Your email

Your contact number

What is your relationship to the disabled person eg. parent, carer, social worker, relative

Details of disabled person

First name

Last name

Age (if under 18)

Nature of disability

Property details of disabled person

Council tax account number

Address of property

Which facilities are in the property to meet the needs of the disabled person

A second bathroom or kitchen required for meeting the needs of the disabled person

Yes

BathroomKitchen

Date from which it has been used for this purpose

A room other than a bathroom, kitchen, toilet or bedroom which is used mainly by the disabled person

Yes

Which room is used and for what purpose?

Date from which it has been used for this purpose

Extra space inside the property to allow for wheelchair use?

Yes

Date use of wheelchair in the property started

Any additional information

Declaration

You must read the undertakings below which you are promising to the Council carefully and make sure that you understand their contents before submitting your application form.

I declare that all the information I have given in this application form is entirely accurate and complete.
I understand and accept that if I give any information that is inaccurate or incomplete, action may be taken against me (including by way of legal proceedings).
I agree that the Council may check the information I have given on this application with third parties (to the extent allowed by the law).
I agree that I must let the Council know immediately in writing (which may include notification on-line and/or by email) about any changes in my circumstances and those contained in the application form which might affect my award.
I agree that the Council may at its discretion share relevant data with third parties, including but not limited to Government departments, local authorities and private sector companies such as banks and organisations (that may lend me money) in each case to the extent allowed by the law.
I agree that the Council will not be responsible for any inaccuracies I make in completing this form.
I agree that the Council will use the information I have provided to process my application and that it may be shared with other Council departments.

Please check this box to confirm you have read and agree to the above declaration

Confirmation

I declare that the answers I have written on this form are correct to the best of my knowledge

Date