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LPS HOUSING BENEFIT APPEAL FORM NOTES This form is for those who have applied for/or are receiving Housing Benefit and who wish to appeal against a decision. Please complete this form in full. The HBA1 leaflet What to do if you think the decision on your Housing Benefit Claim is wrong provides guidance on the appeal process. Please complete in CAPITAL LETTERS using black ink. If you need help completing this form or require it in a different language or format please dial 0300 200 7802 calls charged at local rate. Dial 18001101 for textphone. SECTION 1 YOUR DETAILS Surname First name s in full Date of birth National Insurance Number DD/MM/YY Your daytime contact number Your full postal address Postcode Is someone helping with your appeal. If Yes please provide your representative s details below. Representative s surname Yes No Only one copy of the appeal papers will be sent. Do you want them sent to. Choose the type of hearing you would like for the appeal. You An oral hearing Your representative A paper hearing SECTION 2 DECISION DETAILS You will find this information on the letter we sent telling you about our decision* Your claim number 2. 2 Your account number 2. 3 Date on decision letter Page 1 of 2 SECTION 3 YOUR APPEAL Complete 3. 1 to tell us why you do not agree with our decision* If you are appealing against more than one decision state why you disagree with each one. Complete 3. 2 if you are appealing more than one month after the decision notification was made you must state why your appeal has been delayed* If you need more space please use another sheet of paper. Please write your name and claim number on any extra sheets and attach to this form* Detail your disagreement with the decision in the space below. Reasons for late appeal i*e* more than one month after the date of the decision notification letter SECTION 4 SIGNATURES The information I have provided is true and correct. 4. 1 Signature Date If someone has been officially appointed to act on your behalf or someone has the authority to act for you they should sign here. 4. 4 Date PLEASE RETURN COMPLETED FORM TO Land Property Services Housing Benefit Central Unit Lincoln Building 27 45 Great Victoria Street Malone Lower BELFAST BT2 7SL CONTACT US 0300 200 7802 Textphone 18001101 Email housingbenefit. rating lpsni. gov*uk FOR OFFICIAL USE ONLY Date of notification Date appeal form received in Benefit Office Crown Copyright 2014. Please complete in CAPITAL LETTERS using black ink. If you need help completing this form or require it in a different language or format please dial 0300 200 7802 calls charged at local rate. Dial 18001101 for textphone. SECTION 1 YOUR DETAILS Surname First name s in full Date of birth National Insurance Number DD/MM/YY Your daytime contact number Your full postal address Postcode Is someone helping with your appeal. Dial 18001101 for textphone. SECTION 1 YOUR DETAILS Surname First name s in full Date of birth National Insurance Number DD/MM/YY Your daytime contact number Your full postal address Postcode Is someone helping with your appeal. If Yes please provide your representative s details below. Representative s surname Yes No Only one copy of the appeal papers will be sent.