Residential Financial Assessment Form

Client Details - Step 1 of 6

Title

Clients Name

First

Last

Address or Residential Home Address

Postcode

Date of Birth

Telephone Number

Confirm Email

Marital Status

National Insurance Number

NHS Number / focus Reference Number

A 10-digit number. This is not your National Insurance Number

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Capital, Savings, Bonds and Investments

The following Capital and Income sections refer to the client only.

Use the following field to enter your capital. This includes bank accounts, savings accounts, Post Office accounts, bonds, investments or capital you own. List each account separately and complete every field where possible. If your capital is jointly owned, please enter the full balance and select 'Joint' from the dropdown field.

Account 1

Please state if any of the capital entered below is in joint ownership and if so, with whom. This includes stock and shares.

Name of Bank or Company

Balance / Value (£)

Statement Date

Joint or Sole Account

Is this linked to Life Insurance?

Additional Notes

Account Number, Type, Reference Numbers.

Evidence & Documents

Click or drag files to this area to upload. You can upload up to 3 files.

Please upload and documents or paperwork that will help as evidence, for example 'Bank Statements, Share Certifications, Stock Information, Bond Details'.

Do you have another account?

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Clients Income and Frequency

The following refers to the client's current income. Please enter all that are applicable. Leave fields blank if they do not apply.

Do you receive a Pension?

Do you receive a Pension Credit?

Do you receive Attendance Allowance (AA), Disability Living Allowance (DLA) or Personal Independence Payment (PIP)?

This includes DLA Care/PIP Daily Living Components and DLA/PIP Mobility Components.

Other Income

Please enter any other income you receive.

Income Support

Frequency

Single or Joint Claim

Employment Support Allowance

Frequency

Single or Joint Claim

Universal Credit

Frequency

Single or Joint Claim

Severe Disablement Allowance

Frequency

War Widows Pension

Frequency

War Disablement Pension

Frequency

Industrial Injuries Benefit

Frequency

Wages/Statutory Sick Pay

Frequency

Do you receive any other income?

Any other information relevant to the assessment or Additional Information that has not already been provided

Would you like to upload any other documents?

By sending us copies of your documents or letters, we can better understand the income you are receiving and may prevent delays or the need to contact you later.

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Do you (the client) own or partly own, property or land?

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Residential Assessment Form Declaration

TO BE SIGNED BY ALL CLIENTS, OR THEIR REPRESENTATIVE, WHO HAVE COMPLETED THE FORM

I declare that the information I have given on this form is correct and complete.

I understand I (on behalf of assessed client) will be required to make a contribution towards the service provided and the exact figure will be notified to me.

I (on behalf of assessed client) authorise the Clinical Commissioning Group (CCG) to obtain any details regarding my/assessed clients financial affairs including obtaining information from the Department for Work and Pensions (DWP) and assist me/assessed client by acting on my/assessed clients behalf to help possibly claim any benefit to which I/assessed client may be entitled. This is likely to be done via signposting me/assessed client to what I need to claim via the DWP as I have been informed that the Visiting Officer is not accredited to give full benefits advice which means they cannot completed the required forms. This in no way implies that the CCG has the authority to act as my/assessed client’s agent or appointee.

I (on behalf of assessed client) also undertake to advise the CCG (Community Care Finance section) of any changes in my/assessed clients circumstances relating to my/assessed clients capital and income.

I agree (on behalf of assessed client) to pay the assessed charge directly to the Provider unless otherwise instructed by the CCG.

I hereby confirm and acknowledge that as at today’s date, the raised adult social care debt on my account has been notified to me and I understand that this amount needs to be repaid in accordance with social care charging rules.

You must not give away any financial resources, or deprive yourself/assessed client of them in any other way in order to reduce your/their ability to pay your/their charges. If you do so, the CCG may still regard these resources as belonging to you/assessed client. If you are in any doubt about your situation you should seek legal advice.

Signature

Clear Signature

This can be signed using your computers mouse, or if you're using a touch screen device such as a mobile phone or tablet, you can sign using a stylus or simply using your finger. If you're unable to sign, please select the option below.

I am unable to sign this declaration.

Signatory Full Name

Please enter your email address

Confirm Email

Residential Financial Assessment Form

Capital, Savings, Bonds and Investments

Account 1

Account 2

Account 3

Account 4

Account 5

Account 6

Clients Income and Frequency

Pension Income

Pension Credit

Attendance Allowance (AA), Disability Living Allowance (DLA) & Personal Independence Payment (PIP)

Other Income

Residential Assessment Form Declaration

Unable to Sign Declaration