financial assessment form · financial assessment form page 1 of 25 hertfordshire county council...

Adult Care Services

01438 737400

www.hertsdirect.org/acs

FinancialAssessmentForm

ACS 8

Form issued by: Date:

Client name:

Please return to:

Revised April 2006

Financial Assessment Form

Page 1 of 25

Hertfordshire County Council – Adult Care Services

Financial Assessment Form

Please complete this form if you are (or are considering) receiving a service funded by HertfordshireCounty Council’s Adult Care Services.

This form covers services such as home care and day care, direct payments, supporting people andresidential or nursing care. We only require you to complete the sections that apply to you and yourcircumstances. There are notes at the end of the form to assist you.

If you need help in completing the form please ask your social worker (if you have one), yourhousing provider or support provider. Alternatively you can telephone Hertfordshire County Council’sCustomer Service Centre on:

01438 737400

callers with dialling codes 01923 and 0208 may want to call on: 01923 471400 in order to be charged at the local rate

01438 737599 (textphone)

The Customer Services Centre is open from:

8am to 8pm Monday to Friday and 10am to 4pm on Saturday.

There is information about Adult Care Services on our website www.hertsdirect.org

– you can also contact us by email at [email protected]

Having your say

We would like you to tell us how you think Hertfordshire County Council’s Adult Care Services hasworked with you and what you think of our care services. Our staff will ask you for your views atvarious stages in your contact with us. You can also telephone our customer service centre for a form to be sent to you or ask the operatorfor help in completing the form. A tape version of the form is also available. The operator will askyou various questions and for your comments and then send it onto our policy manager (users andcarers services) so that what you say can be recorded. Your comments are important to us so thatwe can check whether people are satisfied with the service they receive and if not what we canchange to make improvements.

Section 1

Page 2 of 25

Section 1

General section about you

Please use block letters

Title (Mr/Mrs/Miss/Ms): Surname:First name/s:Previous surname/s:Date of birth: Address:

Postcode:

National Insurance Number:

/ / / /Telephone no:

Completing the form. You don’t have tocomplete this form or tell us anything about yourfinances but if you don’t, you will have to pay thefull cost of the services provided. If you decide

not to complete the form please tick here

and sign the declaration below.

■■ I do not wish to disclose details of any of

my financial circumstances, and therefore

I will accept that I will be required to pay

the full charge for the services arranged

by Hertfordshire County Council.

Signature:

Date:

Section 1

About your partner

By ‘partner’ we mean your husband, wife,civilpartner or someone you live with as if you aremarried.

See notes on page 23

Title (Mr/Mrs/Miss/Ms): Surname:First name/s:Previous surname/s:Date of birth: Partner’s address (if different to yours):

Postcode:

National Insurance Number:

/ / / /Telephone no:

OFFICE USE ONLY:

DP

Residential

Section 117

SP

Checked by:

Date:

HCDC

Transport to day care

Section 2

Page 3 of 25

Section 2

People who act on your behalf


Does anyone act on your behalf as a:

Receiver appointed by the Court of Protection

Yes

Do you have a relative or representative who deals with your financial affairs?

Yes No If no, go to Section 3

Appointee (benefits only)

Yes

Power of Attorney

Yes

Enduring Power of Attorney*

Yes

*If Yes, has this been registered with the Court of Protection?*

Yes

*Please provide a certified copy of

the Power of Attorney/Receivership

If the answer is YES to any of the above please give the details below:

Name of Receiver/Appointee/Power of Attorney/Representative:

Date of birth:Relationship to you:Address:

Postcode:Telephone number:

Do you want all your correspondence from Hertfordshire County Council to be sent to this person?

Yes No

Section 3

Others who live with you

Children

Do you have any dependent children?(Under 18 or 19 if still in full-time education)

Yes No

If YES, please give dates of birth:1 2 3 4

Other people who live with you(other than your partner/dependent children)

Give details below of other people who live with you:

Name:Relationship to you:

Name:Relationship to you:

Are any of these people disabled?

Yes No

Are any of these people aged 60 or over?

Yes No

Section 3

Page 4 of 25

Section 4

Page 5 of 25

Section 4

About where you normally live See notes on page 24

Are you a homeowner?

Yes

(If you own your own home and you are entering a care home, please make sure you complete section 10 of this form)

If you own your own home, is it:

Leasehold Freehold

Are you a council tenant / Housing Association tenant?

Yes

Are you a private tenant?

Yes

Are you a boarder/lodger?

Yes

What type of property do you live in?

Flat/Terrace Semi-detached

Detached

Do you live with relatives?

Yes

Do you live in a hostel/group home?

Yes

Do you live in a care home?

Yes

If you live in a care home, have you been payingfor yourself and are approaching HertfordshireCounty Council for assistance with funding?

Yes No

If yes, how much are your fees?

Amount: £

How often? Weekly / fortnightly / 4 weeklyWhen was the last bill paid?

Does it include an amount for the NHS nursing contribution?

Yes No

Section 5

Payment details

You do not need to complete this section if you are applyingfor assistance with Supporting People charges only.

If you would like any invoice for services to be sent to anaddress other than your home, please provide details below.

Name and address for Invoice if different from Section 1:

Title (Mr/Mrs/Miss/Ms): Surname:First name/s:Address:

Postcode:Telephone:Relationship to you:

Payments by standing order:

If you are receiving home care or day care services would you like to payby standing order?

Yes No

Please send a standing order form to:

Section 5

Page 6 of 25

OFFICE USE ONLY: Client name:

Homecare/daycare account reference:

Section 6

Page 7 of 25

Section 6

About the money you receiveSee notes on page 24

Social Security Benefits

Total

Pension Credit: Guarantee Credit

Savings Credit

Income Support

Attendance Allowance: Higher rate

Lower rate

Disability Living Allowance: Higher rate

Care Component: Middle rate

Lower rate

Mobility Component: Higher rate

Lower rate

State Retirement Pension:

War Widows Pension:

War Disablement Pension:

please provide breakdown, you can find this information on your letter from the Veterans Agency

Widows Pension:

Please provide recent evidence

Photocopies are acceptable

Amount£

Self

Amount£

Partner

How often?Weekly/

fortnightly/4 weekly Weekly

Checked by/Date

OFFICE USE ONLY:

Section 6

Page 8 of 25

About the money you receive continued

Working Tax Credit:

Child Tax Credit:

Statutory Sick Pay/Sickness Benefit:

Incapacity Benefit: (or Severe Disablement Allowance for claims made before 2001)Employment Training Allowance:

Child Benefit/Lone Parent Benefit:

Industrial Injuries Disablement Pension:

Carers Allowance:

Maternity Allowance/

Statutory Maternity Pay:

Jobseekers Allowance:

Bereavement Allowance:

Any other social security benefits

you receive:

Are you or your partner receiving or

have you claimed housing benefit?

Does anyone claim Carers Allowance

for looking after you?

Amount£

Self

Amount£

Partner

How often?Weekly/


Checked by/Date

OFFICE USE ONLY:

Yes No Ref. no

Yes No


Total

Please provide recent documentary evidence


Section 6

Page 9 of 25

About the money you receive continued


Earnings or pensions

Earnings:

Please give amount after tax and National Insurance contributions

Occupational Pension/Works Pension:

Please give amount after tax

Personal Pension:

Please give amount after tax

If you are entering a care home, do you want half of your Occupational Pension or Personal Pension to go to your spouse? (NB this will affect any income-relatedbenefits they receive, such as IncomeSupport, Pension Credit, Housing Benefit and Council Tax Benefit)

Amount£

Self

Amount£

Partner

How often?Weekly/


Checked by/Date

OFFICE USE ONLY:

Total

weekly

income

Weekly incomebrought forwardfrom page 9

Yes No



Any other money you receive

Please tell us about any other money coming in:eg income from annuities, Independent Living Fund etc

Amount£

Self

Amount£

Partner

How often?Weekly/


Checked by/Date

OFFICE USE ONLY:

Section 7

Page 10 of 25

Personal(P)

Checked by/Date

OFFICE USE ONLY:

Section 7

Savings, capital or investmentsSee notes on page 24

This section is about the money you have in bank accounts,

savings and investments.

Do you have any of the following?

Please complete sections that apply. Please provide proof of your savings/contracts/agreements/certificates/bank or savings books.

If you don’t have any savings or capital, tick box and go on to the next section.



Bank Current Account:

Bank Deposit Account:

National Savings Certificates:

(please state issue number,and year of issue if known)

Building Society Account:

Premium Bonds:

Girobank:

Amount£

Joint(J)

Section 7

Page 11 of 25

Savings, capital or investments continued




Personal(P)

Checked by/Date

OFFICE USE ONLY:

Total Capital

Investment/income bonds:

Stocks:

Please state number held. If there is not enough space, pleasecontinue on a separate piece of paper.

Shares or Unit Trusts:

Please state number held and details of companies etc. If there is not enough space here, please continue on a separate piece of paper.

Other investments:

Money invested or held abroad:

Capital in a Trust Fund:

Capital held by the Court or Protection:

Date lodged:

ISA’s:

TESSA (2’s):

Amount£

Joint(J)



Section 7

Page 12 of 25

Savings, capital or investments continued

See notes on page 24 Checked by/Date

OFFICE USE ONLY:

Any other type of savings or investments:

Have you ever received any compensation payment? (See notes on page 24)

Yes No

Are you waiting to hear about a compensation claim?

Yes No

If YES, please provide details below:

Total Capital

Do you solely or jointly own any property, building or land, other than the home you live in?

Yes No

Address of property, building or land

Postcode

Details of joint owners

Approximate value

Section 8

Page 13 of 25

Section 8

Expenses you pay to maintain your homeSee notes on page 25

Rent: (amount you pay after Housing Benefit)

Does this include water rates?

Do you have any rent-free weeks?How many?

Mortgage repayments with interest:

Council Tax: (amount you pay after discounts andCouncil Tax Benefit)

Endowment policies linked to your mortgage:

Service charges: (eg communal maintenance)

Ground rent:

Charges for Supporting People Services:

(eg a community alarm, a warden to keep an eye on you, help completing benefit forms and paying bills etc.Please provide a breakdown of charges)

Board/lodging payment/or amount paid if

you live with relatives. Please tell us what thisincludes (eg meals, contribution to fuel bills, laundry)

Amount£

How often?Weekly/monthly/yearly?

Checked by/Date

OFFICE USE ONLY:

Please provide recent evidence


Yes No

Yes No

Section 9

Page 14 of 25

Alarm which enables you to call for assistance

Domestic Services privately purchasedbecause you are unable to do it yourself andthere is no-one else in the household to assist.

Clothing- additional needs because of yourdisability or impairment

Dietary Requirements as a result of medicalcondition

Gardening because you are unable to do itand there is no-one else in the household toassist

Hairdresser because you are unable to doyour own hair due to disability/impairment

Laundry- extra costs e.g. continence related

Medical supplies which are privatelypurchased (non-prescription items)

Personal Care- home care privatelypurchased in addition to care provided byA.C.S.

Prescriptions where you have to pay

Special equipment- relating to your disability(e.g. purchase, plus where you pay formaintenance and repair)

Transport costs to/from ACS Day care

Transport Costs- Other e.g. to go to hospitalor doctor

Window Cleaning because you are unable todo it and there is no-one else in thehousehold to assist

Other

Amount£


Checked by/Date

Weeklyvalue

OFFICE USE ONLY:Description of the expenses:Please give details of the following:

Section 9

Non-Residential ServicesPlease state how much you pay for expenses which are directly as a resul of your impairment ordisability while you continue to live at home. We will require evidence of these expenses so pleaseretain recipts/bills/bank statements.

Section 10

Residential or nursing carePlease only complete this page if you are entering a care home

Building Insurance:

Contents Insurance:

Life Insurance:

Care/Funeral Plans:

TV Licence: (under 75’s)

TV rental:

Gas:

Electricity:

Water/sewerage charges:

Telephone rental only:

Other expenses to do with your home:

(please specify)

Amount£


Checked by/Date

OFFICE USE ONLY:

Section 10

Page 15 of 25

Household expenses:Please give details of the following:

Residential or nursing care continued

Please only complete this page if you are entering a care homeSee notes on page 25

Have you been in hospital in the last 8 weeks?

Yes No

If Yes, please tell us the dates you were in hospital

Dates:

Property and details (owners/occupiers)

(i) If you own your home: (some properties are disregarded, see notes page 25)

Are you the sole owner of the property in which you live?

Yes

or Are you a joint owner of the property in which you live?

Yes

How many joint owners are there (including you)?

Does anyone else live in the property? Yes No

If Yes, give their relationship, if any, to you:Name: Relationship: Age:

Does anyone living in the property have a disability?

Yes No

What is the current estimated market value of your property? £

What is the value of any remaining mortgage on this property? £If you jointly own this property with someone else, how much do you think your share is worth? (Please provide evidence) £

Section 10

Page 16 of 25

Residential or nursing care continued

Have you ever left your property in a deed of trust?

Yes No If yes, please provide a copy

Do you hold the title deeds to this property?

Yes No

If Yes, do you know where they are kept? eg bank, building society

Was your property purchased under a Council “Right to Buy” scheme?

Yes No If Yes, please give date of purchase:

Is the property up for sale or shortly to be put up for sale?

Yes No

(ii) If you own any other property, building or land please give details:

(iii) If you ever previously owned property please give details:

Do you still hold the proceeds?

Yes No

Address:

Postcode:

Date of sale and net proceeds: £

If No, please give details

Section 10

Page 17 of 25

Section 11

Page 18 of 25

Section 11 Declaration Please complete the appropriate section. See notes on page 25

Declaration by Service User

1)I certify that the information I have given is, to the to the best of my knowledge, a full and truestatement of my income, expenses and capital assets. I understand that I may be asked to provideevidence of my income, expenses and capital assets, to Hertfordshire County Council.

2)I will notify Hertfordshire County Council of changes in my expenses or income. 3)I understand that if I do not fully complete this form or provide information requested, I will be liable

to pay full charges/costs for services.4)Where this form is completed as a record of my financial assessment, because I intend to take up a

service provided by Hertfordshire County Council Adult Care Services, I accept that if assessed asliable to pay I must make regular and prompt payments to Adult Care Services or my landlord/supportprovider for the service I receive.

5)I understand that should my payments fall into arrears, Hertfordshire County Council will take actionagainst me, or any person appointed to deal with my finances, to recover any outstanding sums.

6)I agree that other agencies may be contacted to verify any details supplied in this form: thisincludes contacting the Department for Work and Pensions, and my local council housing benefitsection in order to verify the social security benefits I receive. I understand that the informationreceived will be used to assess my contribution. I agree that the Department of Work and Pensionsand local council may pass details of my rate of benefit and, where necessary, the components ofthat rate, to Hertfordshire County Council for the purposes of assessing my contribution to the costof my services only, on a continuing basis. I understand that I may withdraw my consent to thesupply of information regarding my benefit entitlement at any time by notifying, in writing, theappropriate office.

Signature: Date:

(Service user or their legal representative)

Signature: Date:

(Partner, if benefits are claimed jointly)Note: If someone has completed the

form on your behalf, please supply

the information below

Name:

Organisation:

Address:

Postcode:

Relationship to client:

Telephone number:

Benefit entitlement – people aged 60 or older

If the financial assessment reveals that I am entitled toPension Credit or Attendance allowance that I have notclaimed, I agree that Hertfordshire County Council maypass my contact details or my representative’s contactdetails to the Department of Work and Pensions. This information will only be used for the purpose ofassisting me to claim these benefits and I understandtha Hertfordshire County Council are not responsible forensuring that I receive benefits to which I am entitled.

Signature:Service user or their legal representativePrint name:

Date:

Section 12

Page 19 of 25

For Adult Care Services use only

To be completed by care managerResidential or nursing home admissions only

Application details

Application for admission to: (name of home)

Care category:

Planned date of admission :

Planned date of discharge (if short stay/respite care):

Type of placement (please tick box):

Respite care Permanent/long stay

Trial period Financial review

Does this placement include a third party top-up? Please ensure ACS 803 or other evidence has been completed

Yes No Not eligible

Has client applied for Income Support/Pension Credit?

Yes No Not eligible

Is partner receiving Income Support/Pension Credit?

Yes No Not eligible

Former self-funding client – date funding to start:

NHS funded nursing care? Yes No Higher rate

Medium rate

Lower rate

Continence payment: Yes No

Section 12

Page 20 of 25


Please tick box as appropriate

Long stay placements: once the client is in residential or nursing care

what will happen to the property?

Sell property 12 week property disregard package set up

Not sell property/wants Property disregarded – refer to ACS 14/15a deferred payment

Rent property out

Other please state:

(please ensure ACS 14 and 15 are completed and forwarded to the Income Section)

Signed by:

Position: Team:

Print name: Date:

Telephone number:

Copy taken for file

Section 12

Page 21 of 25


To be completed by Community Finance OfficerHome Care or Day Care Services only

Start date of service:

Number of hours: Home care: Day care:

Number of care days:

Method of transport to day centre:

Signed by:

Position: Team:

Print name: Date:

Telephone number:

Exemption applied for: Yes No ACS 16

(completed exemption form)Please tick the box if

Terminal illness Severely mentally impairedeither exemption applies:

Copy taken for file

Notes

Page 22 of 25

Notes

Completing the form

Please complete this form if you are receivingservices provided, paid and arranged byHertfordshire County Council Adult CareServices. These include:■■ Home Care■■ Day Care (day centre)■■ Transport to day care■■ Direct payments■■ Residential and nursing home care■■ Supporting People Services

Supporting People Services

Support providers provide services that help youlive independently such as a warden service,community alarm, or help for people withlearning disabilities or mental health problems.Many support services were included as part ofyour rent before April 2003. Sometimes yoursupport provider is your landlord.

If you receive housing benefit, you will not becharged for your Supporting People Services.

If you are not awarded housing benefit, pleasecomplete this form.

Who should sign the form?

You should sign the form unless someone haslegal authority to act on your behalf, e.g. powerof attorney.

What documents do I have to provide?

If someone employed by Hertfordshire CountyCouncil has helped you complete the form, theywill ask you to show them documents such asbank statements, pension books etc. You will notneed to send copies of these documents withthe form.

If you are completing the form yourself or withsomeone who is not employed by HertfordshireCounty Council, you must provide copies ofdocuments, including:■■ Bank/building society statements■■ Pension books or a letter from the

Department for Work and Pensions■■ Proof of occupational pension■■ Proof of savings bonds, annuities, savings

plans, etc.

You do not have to send us original documents:photocopies are acceptable.

Notes

Page 23 of 25

Section 1

About your partner

By ‘partner’ we mean your husband, wife,civilpartner or someone you live with as if you aremarried.

Do I have to provide details of my partner’s

income and savings?

We follow legislation and guidance set down bythe Government, which tells us if your partner’sincome and savings should be taken intoaccount when we assess how much you have topay for services.

We need to know about partner’s income andsavings if:■■ You are in residential care or■■ You and your partner both receive services

from Adult Care Services or■■ You receive housing related support services

as part of your accommodation (known as"Supporting People" services)

You do not have to provide details of yourpartner’s income or savings. However, it maymean that you pay less if you provide thesedetails, as we will ensure that you are not leftwith less money between you than you need tolive on.

Section 2

People who act on your behalf

Types of representative

An Agent

A person who has been nominated by you tocollect Social Security Benefits in your behalf.

An Appointee

A person appointed by The Department for Workand Pensions, who acts on your behalf, if youhave lost the capacity to act. The person actingon your behalf will deal with issues concerningthe claiming and payment of Social SecurityBenefits.

Power of Attorney/

Enduring Power of Attorney

A person nominated by you to act on yourbehalf, to deal with all issues relating to yourfinances, if you lose the capacity to act. Theperson needs to be nominated by you beforeyou have lost the capacity to act. The personacting on your behalf will need to register withthe Court of Protection.

A Receiver

A person nominated by the Court of Protectionto act on your behalf. The person will need to beregistered by the Court of Protection as theReceiver. Any funds belonging to you will beheld on your behalf by the Public GuardianshipOffice.

Notes

Page 24 of 25

Section 4

Where you normally live

We need to know what type of housing you livein as this affects how we assess how much youmay have to pay.

Section 6

About the money you receive


What if I am unsure about the benefits

I receive?

Just write what you know on the form, and wewill check with the Department for Work andPensions or local Council Housing BenefitSection on your behalf. Please make sure yousign the declaration in Section 11 so we can do this.

What happens if I have applied for benefit

and have not received a decision yet?

Please indicate this on the form. Don’t delay insending the form if you are waiting for a decision.

Earnings or pensions

Earned income is not taken into account whenwe work out what you have to pay for someservices, such as homecare, day services andSupporting People Services.

If you are in a care home, you can choose togive half of your occupational or personalpension to your husband or wife. If you do this itwill be ignored when we are working out yourcharge. Please speak to your social worker ifyou would like more information about this.

Section 7

Savings, capital and investments

What if I don’t know what my shares are

worth?

We will work out for you what shares andnational savings certificates are currently worth.Any other accounts and savings bonds will berecorded at the value you declare on the form.

What if some accounts are in joint names?

Please state whether the accounts/savings arein "J" Joint or "P" Personal names.

Compensation payments

Compensation payments include:■■ A compensation payment for personal injury■■ Vaccine damage payments■■ Payments for former prisoners of the

Japanese during the Second World War■■ Payment from the Government trust for

people with variant CJD.■■ Payment from the Government fund for

people infected with Hepatitis C as a result ofNHS treatment.

Some payments are ignored in the financialassessment.

Please tell us if you have received acompensation payment, and what is was paid for.We may need to contact you for further details.If you are expecting a compensation payment,please let us know when the payment is made,how much it is for and where it is lodged i.e.with the Court of Protection.

Notes

Page 25 of 25

Section 8

Expenses to maintain your home

We need to know details of:■■ Your rent and the council tax you pay after

any discounts or benefits■■ Any rent free weeks■■ Any support services you receive and how

much you pay towards them.

Section 9

Disability related expenses

We need to know details of:■■ Your expenses which are directly as a result

of your impairment or disability while youcontinue to live at home.

Section 10

Residential and nursing careif you own property

If your stay is permanent (or becomespermanent) and you have below the maximumsavings set by the Government annually, you willbe given any necessary assistance with fundinguntil your property is sold. You will still berequired to pay a contribution towards your carecosts out of your weekly income.

Once the property is sold, you will have toreimburse any care costs that HertfordshireCounty Council Adult Care Services has paid tothe residential or nursing home on your behalf.However, the value of your property is ignoredfor the first 12 weeks that you are in the carehome.

Please provide as much evidence as possible ofjoint ownership, mortgages and/or property

previously owned in the last two years.Preferably these should be sent with this form.

We will contact you or your representative if anyfurther documents are needed. We will return alloriginal documents without delay.

Under some circumstances property that youown will be disregarded for assessmentpurposes:■■ If your spouse or partner still occupies the

home■■ If a close relative aged 60 or over is

occupying the home■■ If your former partner who is a lone parent is

occupying the home■■ If a child aged under 16 who you are liable to

maintain is occupying the home■■ If a close relative who is incapacitated is

occupying the homeWe may also be able to disregard the propertyin other limited circumstances. Please ask yoursocial worker for details.

Section 11

Benefit entitlement – people aged 60 or older

We want to help you to claim any Social Securitybenefits such as Pension Credit or AttendanceAllowance that you are entitled to and may helpyou pay any charges for your care. We are ableto ask your local Pensions Service (Departmentof Work and Pensions) to assist you with aclaim but we will not pass on your details tothem without your permission. If you would likeus to pass on your details, the service user ortheir legal representative must sign theappropriate declaration.

Please note that the Department of Work andpensions are the government departmentresponsible for administering social securitybenefits. The County Council cannot decideyour entitlement, we can only assist you toclaim.

Hertfordshire County Council

Adult Care Services

County Hall, Pegs Lane, Hertford, SG13 8DF

DPPJ11000

Hertfordshire County Council –

making Hertfordshire a better place to live

by providing:

Care for older people

Support for schools, pupils and parents

Support for carers

Fire and rescue

Fostering and adoption

Support for people with disabilities

Libraries

Admission to schools

Road maintenance and safety

Protection for adults and children at risk

Trading standards and consumer protection

Household waste recycling centres

These are only some of our services.

Find out more at www.hertsdirect.org

or email us at [email protected]

Every Hertfordshire library has free internet access

for the public

Issue 5 - April 06 - ACS 8

Related leaflets or books

■ Your home care service

■ Finding the right care home

■ Direct payments – arranging your own service

■ Will I have to pay?

■ Paying for residential care

■ Moving into a care home – what happens to my own home?

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