1Page 1 2Page 2 3Summary Progress Before you begin This discount is for a terminally ill person who lives at the given address on this form. Confirmation I confirm a registered medical professional has confirmed a terminal illness under the Special Rules (a condition expected to progress and cannot be cured). Applicant details First name Last name Email address Telephone (optional) Please include your phone number if this is your preferred method of contact. Are you the person who is terminally ill? Yes No First name of terminally ill person Last name of terminally ill person What is your relationship to the person who is terminally ill? I am their partner I am a family member Other Describe your relationship Date of birth of terminally ill person Day Month Year Council tax property details Council Tax account number (optional) You can find this on your Council Tax bill Property address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Is the person who is terminally ill currently residing at this address? Yes No This discount only applies where the person is resident at the billed address. You are not eligible to apply for this discount. Please do not continue with this form, as it cannot be completed. No information is required, please proceed to the next page. Evidence – SR1 form To process your application, we need a signed copy of the SR1 form. Tell us how you would like to provide it. I can upload a copy or image of the form I will send it later I give consent for you to contact my medical practitioner to obtain it. Upload the form You must upload both sides of the form – these can be a photograph or scanned image. To upload multiple files, hold 'Ctrl' (Windows) or 'Cmd' (Mac) when choosing files to upload. You must email this to us within 14 days. We will provide instructions for where to send it in the confirmation email you will receive. Medical practitioner details Name of registered medical practitioner Name of medical practice or hospital Address Town/City Postcode Telephone number Email address Permission confirmation I confirm I give permission for Liverpool City Council to contact the medical professional listed above, to request confirmation of the SR1 form under the Special Rules for terminal illness. Please note not providing your SR1 form at this stage may cause further delays to your application. Declaration By submitting this form, you agree to the following: I declare that the person who is terminally ill lives at the property listed in this application, and that the information I have provided is true and complete to the best of my knowledge. I understand that the council may contact me or the medical professional to verify details and that giving false information may lead to action being taken. I understand that you will use the information given to assess eligibility for Council Tax discount under Section 13a of the Local Government Finance Act 1992. For details, please see our Privacy Notice. You must agree to the declaration statements in order to submit this application. Do you want us to contact you about your possible entitlement to any benefits, discounts, grants and council services? Yes No Contact preference (optional) Email Phone No preference No information is required, please proceed to the next page. Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page Loading form summary...