Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1698075832327.pdf (Saint Kitts and Nevis)
GOVERNMENT OF ST. KITTS AND NEVIS CLAIM FOR COVID-19 INCOME SUPPORT Section A: Applicant's Details 1.

Social Security No.

2.

FIRST NAME MIDDLE NAME(S) SURNAME 3.

Date of Birth (dd/mm/yyyy) 6.

Street Address 4.

Gender Male Female 5.

Occupation City/Town/Village ________________________ Island St. Kitts Nevis 7.

P.O.

Box No.

8.

E-mail Address 9.

Tel./Cellular No.

______________________________________ Section B: Employment History 10.

Name of Current/Last Employer 11.


Date Last Employed (dd/mm/yyyy) 13.

Period Employed from: (dd/mm/yyyy) 14.

Name of Secondary Employer 12.

Last pay date (dd/mm/yyyy) To: (dd/mm/yyyy) 15.

Period Employed was from: (dd/mm/yyyy) To: (dd/mm/yyyy) Section C: Eligibility 16.

Are you currently employed?

17.

If yes; have reduced hours?

18.

Are you self-employed?

19.

If so; are you registered with the Social Security Board?

20.

Have you received Severance Payment(s) after 31 March 2020?

21.
21.

If yes, state the total amount received Yes Yes Yes Yes Yes No No No No No Telephone: (869) 467 – 1092 Cell: (869) 662 - 1700 Email Address: covidsupport@gov.kn 22.

Are you receiving payments under the Poverty Alleviation Programme (PAP)?

23.a Are you receiving any other form of payments from the Government?

Yes No Yes No 23.b If yes to 23.a, please specify _______________________________ 24.
Are you receiving pension payments from the Social Security Board, Government of St. Kitts and Nevis or any other institution?

Social Security Other: _____________________ Government None I hereby authorize and request the Ministry of Finance, Government of St. Kitts and Nevis, to transfer the COVID-19 Income Support payment to the designated financial institution for deposit in my account.
If the electronic transmission for this authorization for any reason results in an overpayment of the Income Support payment due and payable to me, I hereby authorize the Ministry of Finance to either withhold a sum equal to the overpayment from my next Income Support payment or seek full reimbursement by whatever means is appropriate.
If any action taken by me, without adequate notification to the Ministry of Finance, results in non- acceptance of the transfer by the designated financial institution, I understand that the Ministry of Finance assumes no responsibility for processing supplemental Income Support payments until the funds are returned to the Government of St. Kitts and Nevis by the financial institution.

Section D: Banking Information Please enter your Bank details for payment of your Income Support: 25.

Name on Account 26.
Name on Account 26.

Account No.

27.

Name of Financial Institution Select type of Account – Savings - Chequing - Telephone: (869) 467 – 1092 Cell: (869) 662 - 1700 Email Address: covidsupport@gov.kn Section E: Declaration I hereby declare that the information given in this claim is true to the best of my knowledge and belief and that I will not receive or keep any payment in respect of any period for which I am employed or do not meet the criteria.
a. I hereby authorize the Ministry of Finance and any Government Agency approved to process my claim, to use a copy (including electronic copy) of this form and the information contained therein, as well as other information previously provided to other Government Agencies by me, for the purpose of determining my eligibility for benefits and for processing such benefits.
b. I understand that there may be some circumstances in which this information may be shared with other parties where necessary for routine purposes including: i. for auditing of programme eligibility and payments; ii.

to establish or verify information provided by programme applicants; and iii.

for administering/issuing programme payments.

c. I have read Section E: Declaration and agree to the disclosures above.

28.

Claimant's Signature 29.

Date Signed (dd/mm/yyyy) IMPORTANT NOTES: I.


2. obtaining benefit will be liable to prosecution.

This form MUST be accompanied by a copy of a valid Social Security card.

Warning: Any person who knowingly makes any false statement or false representation for the purpose of Telephone: (869) 467 – 1092 Cell: (869) 662 - 1700 Email Address: covidsupport@gov.kn For Official Use Date Received Verification Document Received Claim Number 30.

Amount Payable 31.

Comment 32.

Signature of Verification Officer 33.


Date (dd/mm/yyyy) 34.

Signature of Approver 35.

Date (dd/mm/yyyy) Telephone: (869) 467 – 1092 Cell: (869) 662 - 1700 Email Address: covidsupport@gov.kn