Form PC1
About you
Q1. Title
About you
Q2. Last name
About you
Q3. First name
About you
Q4. All other last names you have used or have been known by. Include maiden names, all former married names and all changes of surname or family name.
About you
Q5. Date of birth
Guidance: DD/MM/YYYY
About you
Q6. National Insurance (N I) number. You can get this from your National Insurance number card, letters about benefits, payslips or form P60.
About you
Q7. Your address
About you
Q8. Your contact address (if different). Postcode
About you
Q9. Phone number. If you provide your mobile number we may contact you by text message to deal with your claim, or any queries you may have, as quickly as possible.
About you
Q10. Are you registered blind or severely sight impaired?
Options: No; Yes
About you
Q11. Do you want to speak to us in Welsh?
Options: No; Yes
About you
Q12. Are you able to speak to us in English?
Options: No; Yes
About you
Q13. What language would you like us to use when we speak to you?
About your partner
Q14. Do you have a partner? We use 'partner' to mean a person you are married to or a person you live with as if you are married to them, or a civil partner or a person you live with as if you are civil partners.
Options: No; Yes
About your partner
Q14. Does your partner live permanently in a care home?
Options: No; Yes
About your partner
Q14. Are you separated from your partner? If you are separated only because someone is temporarily in a hospital or care home, tick No.
Options: No; Yes
About your partner
Q15. Does your partner live permanently in a care home?
Options: No; Yes
About your partner
Q16. Are you separated from your partner? If you are separated only because someone is temporarily in a hospital or care home, tick No.
Options: No; Yes
About your partner
Q17. Does your partner agree to you making this application?
Options: No; Yes
About your partner
Q18. Your partner’s title. For example, Mr, Mrs, Miss, Ms or other.
About your partner
Q19. Your partner’s last name
About your partner
Q20. All your partner’s other names in full. Include maiden names, all former married names and all changes of surname or family name.
About your partner
Q21. All other surnames or family names your partner has used or has been known by. Include maiden names, all former married names and all changes of surname or family name.
About your partner
Q22. Your partner’s date of birth. DD/MM/YYYY
Guidance: DD/MM/YYYY
About your partner
Q23. Your partner’s N I number. You can get this from your National Insurance number card, letters about benefits, payslips or form P60.
About your partner
Q24. Is your partner registered blind or severely sight impaired?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q25. Do you want to claim Pension Credit for any children or qualifying young people?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q25. How many children do you want to claim for? If you want to claim for more than 2 children or qualifying young people, please provide more details in the Other information section.
About any child/children and qualifying young people you want to claim for
Q26. First name
About any child/children and qualifying young people you want to claim for
Q27. Last name
About any child/children and qualifying young people you want to claim for
Q28. Sex of child. Female or Male.
Options: Female; Male
About any child/children and qualifying young people you want to claim for
Q29. Child's date of birth. DD/MM/YYYY
Guidance: DD/MM/YYYY
About any child/children and qualifying young people you want to claim for
Q30. What date do you want to claim for the child from?
About any child/children and qualifying young people you want to claim for
Q31. What date did you become responsible for the child?
About any child/children and qualifying young people you want to claim for
Q32. Does the child live with you all the time?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q33. How often do they live with you? For example, 3 days a week.
Guidance: For example, 3 days a week.
About any child/children and qualifying young people you want to claim for
Q34. Where else does the child live? Postcode
About any child/children and qualifying young people you want to claim for
Q35. Who do you share caring responsibilities with?
About any child/children and qualifying young people you want to claim for
Q36. If you have only just taken over responsibility for the child, who was responsible for them before you?
About any child/children and qualifying young people you want to claim for
Q37. Do you get Child Benefit for this child?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q38. Who claims Child Benefit for this child?
About any child/children and qualifying young people you want to claim for
Q39. What is the N I number of the person who claims Child Benefit?
About any child/children and qualifying young people you want to claim for
Q40. Is the child aged between 16 and 19?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q41. Is the child in full time education, non-advanced education or an approved training course?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q42. When did the non-advanced education or approved training start?
About any child/children and qualifying young people you want to claim for
Q43. Is the child looked after by the local authority, not including respite care?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q44. Is the child in prison or custody pending trial or sentence?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q45. Is the child currently away from home, but in Great Britain?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q46. How long in total are they expected to be absent for?
About any child/children and qualifying young people you want to claim for
Q47. If more than 52 weeks, why is the child away from home?
About any child/children and qualifying young people you want to claim for
Q48. Is the child currently outside Great Britain?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q49. How long in total are they expected to be absent for?
About any child/children and qualifying young people you want to claim for
Q50. If more than 4 weeks, why is the child absent from Great Britain?
About any child/children and qualifying young people you want to claim for
Q51. Is the child entitled to Disability Living Allowance?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q52. What rate of Disability Living Allowance is the child entitled to? Care Component highest rate, middle rate, lowest rate. Mobility Component higher rate, lower rate.
Options: Care Component highest rate; Care Component middle rate; Care Component lowest rate; Mobility Component higher rate; Mobility Component lower rate
About any child/children and qualifying young people you want to claim for
Q53. Is the child entitled to Child Disability Payment?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q54. What rate of Child Disability Payment is the child entitled to? Care Component highest rate, middle rate, lowest rate. Mobility Component higher rate, lower rate.
Options: Care Component highest rate; Care Component middle rate; Care Component lowest rate; Mobility Component higher rate; Mobility Component lower rate
About any child/children and qualifying young people you want to claim for
Q55. Is the child entitled to Personal Independence Payment?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q56. What rate of Personal Independence Payment is the child entitled to? Daily living enhanced rate, standard rate. Mobility enhanced rate, standard rate.
Options: Daily living enhanced rate; Daily living standard rate; Mobility enhanced rate; Mobility standard rate
About any child/children and qualifying young people you want to claim for
Q57. Is the child entitled to Adult Disability Payment?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q58. What rate of Adult Disability Payment is the child entitled to? Daily living enhanced rate, standard rate. Mobility enhanced rate, standard rate.
Options: Daily living enhanced rate; Daily living standard rate; Mobility enhanced rate; Mobility standard rate
About any child/children and qualifying young people you want to claim for
Q59. Is the child certified as severely sight impaired or blind by a consultant ophthalmologist?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q60. Have you claimed Tax Credits in the last 12 months?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q61. Are you still claiming Tax Credits?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q62. When did the Tax Credit claim come to an end?
About any child/children and qualifying young people you want to claim for
Q63. What date do you want to claim for the child from?
About any child/children and qualifying young people you want to claim for
Q64. What date did you become responsible for the child?
About any child/children and qualifying young people you want to claim for
Q65. Does the child live with you all the time?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q66. How often do they live with you? For example, 3 days a week.
Guidance: For example, 3 days a week.
About any child/children and qualifying young people you want to claim for
Q67. Where else does the child live? Postcode
About any child/children and qualifying young people you want to claim for
Q68. Who do you share caring responsibilities with?
About any child/children and qualifying young people you want to claim for
Q69. If you have only just taken over responsibility for the child, who was responsible for them before you?
About any child/children and qualifying young people you want to claim for
Q70. Do you get Child Benefit for this child?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q71. Who claims Child Benefit for this child?
About any child/children and qualifying young people you want to claim for
Q72. What is the NI number of the person who claims Child Benefit?
About any child/children and qualifying young people you want to claim for
Q73. Is the child aged between 16 and 19?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q74. Is the child in full time education, non-advanced education or an approved training course?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q75. When did the non-advanced education or approved training start?
About any child/children and qualifying young people you want to claim for
Q76. Is the child looked after by the local authority, not including respite care?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q77. Is the child in prison or custody pending trial or sentence?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q78. Is the child currently away from home, but in Great Britain?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q79. How long in total are they expected to be absent for?
About any child/children and qualifying young people you want to claim for
Q80. If more than 52 weeks, why is the child away from home?
About any child/children and qualifying young people you want to claim for
Q81. Is the child currently outside Great Britain?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q82. How long in total are they expected to be absent for?
About any child/children and qualifying young people you want to claim for
Q83. If more than 4 weeks, why is the child absent from Great Britain?
About any child/children and qualifying young people you want to claim for
Q84. Is the child entitled to Disability Living Allowance?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q85. What rate of Disability Living Allowance is the child entitled to? Care Component highest rate, middle rate, lowest rate. Mobility Component higher rate, lower rate.
Options: Care Component highest rate; Care Component middle rate; Care Component lowest rate; Mobility Component higher rate; Mobility Component lower rate
About any child/children and qualifying young people you want to claim for
Q86. Is the child entitled to Child Disability Payment?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q87. What rate of Child Disability Payment is the child entitled to? Care Component highest rate, middle rate, lowest rate. Mobility Component higher rate, lower rate.
Options: Care Component highest rate; Care Component middle rate; Care Component lowest rate; Mobility Component higher rate; Mobility Component lower rate
About any child/children and qualifying young people you want to claim for
Q88. Is the child entitled to Personal Independence Payment?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q89. What rate of Personal Independence Payment is the child entitled to? Daily living enhanced rate, standard rate. Mobility enhanced rate, standard rate.
Options: Daily living enhanced rate; Daily living standard rate; Mobility enhanced rate; Mobility standard rate
About any child/children and qualifying young people you want to claim for
Q90. Is the child entitled to Adult Disability Payment?
Options: No; Yes
About any child/children and qualifying young people you want to claim for
Q91. What rate of Adult Disability Payment is the child entitled to? Daily living enhanced rate, standard rate. Mobility enhanced rate, standard rate.
Options: Daily living enhanced rate; Daily living standard rate; Mobility enhanced rate; Mobility standard rate
About where you live
Q92. Do you live permanently in a care home?
Options: No; Yes
About where you live
Q93. Does anyone live in your household apart from you and your partner?
Options: No; Yes
About where you live
Q94. What is their name and relationship to you?
About where you live
Q95. Are you or your partner responsible for paying the rent, Council Tax or both for the place where you live? If they are paid through Housing Benefit or Council Tax reduction, still tick Yes.
Options: No; Yes
About where you live
Q96. What is the name of your council?
About where you live
Q97. Have you claimed or are you about to claim Housing Benefit?
Options: No; Yes
About where you live
Q98. Have you applied or are you about to apply for a reduction in Council Tax?
Options: No; Yes
About where you live
Q99. Do you or your partner pay service charges for the place where you live? For example, money for upkeep of the building (in Scotland, called 'factoring').
Options: No; Yes
Guidance: For example, money for upkeep of the building (in Scotland, called 'factoring').
About where you live
Q100. Do you rent your property or own it? Rent it / Own it.
Options: Rent it; Own it
About where you live
Q101. Do you or your partner pay ground rent for the place where you live? In Scotland, this is called 'ground annual'.
Options: No; Yes
Guidance: In Scotland, this is called 'ground annual'.
About where you live
Q102. When the lease on your home was granted, was it for more than 21 years?
Options: No; Yes
About where you live
Q103. Do you or your partner share the rent or mortgage for the place where you live with anyone else? If you and your partner just share with each other, tick No.
Options: No; Yes
Guidance: If you and your partner just share with each other, tick No.
About where you live
Q104. Do you or your partner have a mortgage or home loan on your home?
Options: No; Yes
About money you have, including savings and investments
Q105. Do you or your partner have any money, including savings and investments?
Options: No; Yes
Guidance: Please check the notes for what we mean by savings and investments.
About money you have, including savings and investments
Q106. What is the total amount? If this amount is more than £10,000, please fill in and return the form About Savings and Investments (PC1H).
About money you have, including savings and investments
Q107. Apart from the place where you live, do you or your partner own any other property or land in this country or abroad? If it is on a mortgage or loan, tick Yes.
Options: No; Yes
Guidance: If it is on a mortgage or loan, tick Yes.
About money you have, including savings and investments
Q108. Tell us about the property or land. If you need to tell us more, go to Other information on page 19.
Guidance: If you need to tell us more, go to Other information on page 19.
About money you have, including savings and investments
Q109. Have you claimed any benefits that you are waiting to hear about?
Options: No; Yes
About money you have, including savings and investments
Q110. Which benefits are you waiting to hear about?
About benefits - You
Q111. Your carer's full name
About benefits - You
Q112. Your carer's N I number
About benefits - You
Q113. Do you spend 35 hours a week or more looking after someone who is getting or waiting to hear about: Attendance Allowance, Pension Age Disability Payment, Constant Attendance Allowance, Disability Living Allowance, Scottish Adult Disability Living Allowance, Child Disability Payment, Personal Independence Payment or Adult Disability Payment?
Options: No; Yes; Not known
About benefits - Your partner
Q114. Has your partner claimed any benefits that you are waiting to hear about?
Options: No; Yes
About benefits - Your partner
Q115. Which benefits is your partner waiting to hear about?
About benefits - Your partner
Q116. Full name of your partner's carer
About benefits - Your partner
Q117. N I number of your partner's carer
About benefits - Your partner
Q118. Does your partner spend 35 hours a week or more looking after someone who is getting or waiting to hear about: Attendance Allowance, Pension Age Disability Payment, Constant Attendance Allowance, Disability Living Allowance, Scottish Adult Disability Living Allowance, Child Disability Payment, Personal Independence Payment or Adult Disability Payment?
Options: No; Yes; Not known
About pensions
Q119. Have you or your partner paid into a private pension scheme from which you expect to get money in the next 12 months?
Options: No; Yes
About pensions
Q120. Do you or your partner get a private pension, money from a place where you used to work or any other pension? If you expect to get a pension in the next 12 months, please tick Yes. Do not count any State Pension paid by the Department for Work and Pensions.
Options: No; Yes
About pensions
Q121. Who pays the pension?
About pensions
Q122. What type of pension is it?
About pensions
Q123. How much is paid? £
About pensions
Q124. How often is it paid?
About pensions
Q125. When is the pension normally received? For example, the last day of the month.
Guidance: For example, the last day of the month.
About pensions
Q126. When did you receive your latest payment?
About pensions
Q127. Does the pension increase each year?
Options: No; Yes
About pensions
Q128. Who gets the pension? You / Your partner.
Options: You; Your partner
About pensions
Q129. If you or your partner expect to get a pension in the next 12 months, when do you expect to get the first payment?
About pensions
Q130. Who pays the pension? You / Your partner.
Options: You; Your partner
About pensions
Q131. What type of pension is it?
About pensions
Q132. How much is paid? £
About pensions
Q133. How often is it paid?
About pensions
Q134. When is the pension normally received? For example, the last day of the month.
Guidance: For example, the last day of the month.
About pensions
Q135. When did you receive your latest payment?
About pensions
Q136. Does the pension increase each year?
Options: No; Yes
About pensions
Q137. Who gets the pension? You / Your partner.
Options: You; Your partner
About pensions
Q138. If you or your partner expect to get a pension in the next 12 months, when do you expect to get the first payment?
About work
Q139. Have you left self-employed work in the last 3 months?
Options: No; Yes
About work
Q140. Are you doing any paid work now?
Options: No; Yes
About work
Q141. Is this self-employed work?
Options: No; Yes
About work
Q142. Has your partner left self-employed work in the last 3 months?
Options: No; Yes
About other money coming in
Q143. Do you or your partner have any other money coming in? You do not need to tell us about benefits paid by the Department for Work and Pensions.
Options: No; Yes
About other money coming in
Q144. What is this money?
About other money coming in
Q145. How much is paid? £
About other money coming in
Q146. How often is it paid?
About other money coming in
Q147. Who is paid the money? You / Your partner.
Options: You; Your partner
About other money coming in
Q148. What is this money?
About other money coming in
Q149. How much is paid? £
About other money coming in
Q150. How often is it paid?
About other money coming in
Q151. Who is paid the money? You / Your partner.
Options: You; Your partner
About other money coming in
Q152. What is this money?
About other money coming in
Q153. How much is paid? £
About other money coming in
Q154. How often is it paid?
About other money coming in
Q155. Who is paid the money? You / Your partner.
Options: You; Your partner
About other money coming in
Q156. What is this money?
About other money coming in
Q157. How much is paid? £
About other money coming in
Q158. How often is it paid?
About other money coming in
Q159. Who is paid the money? You / Your partner.
Options: You; Your partner
About other money coming in
Q160. Do you or your partner expect to start getting any money in the next 12 months?
Options: No; Yes
About other money coming in
Q161. Who will pay this money?
About other money coming in
Q162. How much will be paid? £
About other money coming in
Q163. How often will it be paid?
About other money coming in
Q164. Who will be paid the money? You / Your partner.
Options: You; Your partner
About other money coming in
Q165. When do you or your partner expect to start getting this money?
Other things we need to know
Q166. Are you in hospital as an inpatient?
Options: No; Yes
Other things we need to know
Q167. Are you staying temporarily in a care home?
Options: No; Yes
Other things we need to know
Q168. Do you have the right to reside in the UK? For example, you have the right to reside in the UK if you are a British citizen.
Options: No; Yes
Guidance: For example, you have the right to reside in the UK if you are a British citizen.
Other things we need to know
Q169. At any time, have you come to live or returned to live in the UK from abroad?
Options: No; Yes
Other things we need to know
Q170. What is your nationality?
Other things we need to know
Q171. Which country have you come from?
Other things we need to know
Q172. What date did you last come to the UK?
Other things we need to know
Q173. Was this to work in the UK?
Options: No; Yes
Other things we need to know
Q174. Has the Home Office put a limit on how long you can stay in the UK?
Options: No; Yes
Other things we need to know
Q175. Does your passport or eVisa say no recourse to public funds? The passport will have a stamp in it or you will have a Home Office letter.
Options: No; Yes
Guidance: The passport will have a stamp in it or you will have a Home Office letter.
Other things we need to know
Q176. Tell us your immigration status share code, if you have one. This is usually made up of 9 numbers and letters, and starts with an ‘S’. For more information on immigration status share codes, please visit www.gov.uk/view-prove-immigration-status.
Guidance: For more information on immigration status share codes, please visit www.gov.uk/view-prove-immigration-status.
Other things we need to know
Q177. If you do not have an immigration status share code, please tell us the number you use to sign in to your UKVI account. This is usually an ID document number that you used to create your account.
Other things we need to know
Q178. If you do not have a UKVI account, please visit www.gov.uk/guidance/online-immigration-status-evisa.
Other things we need to know
Q179. Have you come to the UK under the Family Reunion Scheme?
Options: No; Yes
Other things we need to know
Q180. Name of the sponsor
Other things we need to know
Q181. Address of the sponsor. Postcode
Other things we need to know
Q182. Home Office reference number
Other things we need to know
Q183. What date did the sponsor sign the sponsorship undertaking?
Other things we need to know
Q184. Are you an asylum seeker?
Options: No; Yes
Other things we need to know
Q185. Did you first apply for asylum before 3 April 2000?
Options: No; Yes
Other things we need to know
Q186. Have you recently had a successful decision on your asylum application?
Options: No; Yes
Other things we need to know
Q187. What was the date when you got the successful decision of your asylum application?
Other things we need to know
Q188. Have you been supported by the Home Office while waiting for a decision on your asylum application?
Options: No; Yes
Other things we need to know
Q189. Is your partner in hospital as an inpatient?
Options: No; Yes
Other things we need to know
Q190. Is your partner staying temporarily in a care home?
Options: No; Yes
Other things we need to know
Q191. Does your partner have the right to reside in the UK? For example, you have the right to reside in the UK if you are a British citizen.
Options: No; Yes
Guidance: For example, you have the right to reside in the UK if you are a British citizen.
Other things we need to know
Q192. At any time, has your partner come to live or returned to live in the UK from abroad?
Options: No; Yes
Other things we need to know
Q193. What is your partner's nationality?
Other things we need to know
Q194. Which country has your partner come from?
Other things we need to know
Q195. What date did your partner last come to the UK?
Other things we need to know
Q196. Was this to work in the UK?
Options: No; Yes
Other things we need to know
Q197. Has the Home Office put a limit on how long your partner can stay in the UK?
Options: No; Yes
Other things we need to know
Q198. Does your partner's passport or eVisa say no recourse to public funds? The passport will have a stamp in it or you will have a letter from the Home Office.
Options: No; Yes
Guidance: The passport will have a stamp in it or you will have a letter from the Home Office.
Other things we need to know
Q199. Tell us your partner's immigration status share code, if they have one. This is usually made up of 9 numbers and letters, and starts with an ‘S’. For more information on immigration status share codes, please visit www.gov.uk/view-prove-immigration-status.
Guidance: For more information on immigration status share codes, please visit www.gov.uk/view-prove-immigration-status.
Other things we need to know
Q200. If your partner does not have an immigration status share code, please tell us the number you use to sign in to your UKVI account. This is usually an ID document number that you used to create your account.
Other things we need to know
Q201. If your partner does not have a UKVI account, please visit www.gov.uk/guidance/online-immigration-status-evisa.
Other things we need to know
Q202. Has your partner come to the UK under the Family Reunion Scheme?
Options: No; Yes
Other things we need to know
Q203. Name of the sponsor
Other things we need to know
Q204. Address of the sponsor. Postcode
Other things we need to know
Q205. Home Office reference number
Other things we need to know
Q206. What date did the sponsor sign the sponsorship undertaking?
Other things we need to know
Q207. Is your partner an asylum seeker?
Options: No; Yes
Other things we need to know
Q208. Did your partner first apply for asylum before 3 April 2000?
Options: No; Yes
Other things we need to know
Q209. Has your partner recently had a successful decision on their asylum application?
Options: No; Yes
Other things we need to know
Q210. What was the date when your partner got the successful decision of their asylum application?
Other things we need to know
Q211. Has your partner been supported by the Home Office while waiting for a decision on their asylum application?
Options: No; Yes
Other things we need to know
Q212. When do you want to apply from? We will consider your application from the date you choose. The qualifying age.
Other things we need to know
Q213. Please tell us why you think you qualify from this date.
Other information
Q214. Please use this space to tell us anything else you think we might need to know.
How we pay you
Q215. How often do you want to be paid? 4-Weekly / Fortnightly / Weekly.
Options: 4-Weekly; Fortnightly; Weekly
About the account you want to use
Q216. Name of the account holder. This should be exactly as shown on the chequebook or statement.
About the account you want to use
Q217. Full name of bank or building society
About the account you want to use
Q218. Sort code. Please tell us all 6 numbers, for example 12-34-56.
Guidance: Please tell us all 6 numbers, for example 12-34-56.
About the account you want to use
Q219. Account number. Most account numbers are 8 characters long, some can have up to 10 characters.
Guidance: Most account numbers are 8 characters long, some can have up to 10 characters.
About the account you want to use
Q220. Building society roll or reference number. If you are using a building society account, you may need to tell us a roll or reference number. This may be made up of letters and numbers and is up to 18 characters long. If you are not sure if the account has a roll or reference number, ask the building society.
Guidance: If you are using a building society account, you may need to tell us a roll or reference number. This may be made up of letters and numbers and is up to 18 characters long. If you are not sure if the account has a roll or reference number, ask the building society.
Your declaration
Q221. Have you signed this form for someone else?
Options: No; Yes
For people filling in this form for someone else
Q222. Your contact address. Postcode
For people filling in this form for someone else
Q223. Your phone number
For people filling in this form for someone else
Q224. Your National Insurance number
Your declaration
Q225. Your signature
Your declaration
Q226. Date
Your declaration
Q227. Please make sure you have read and understand the declaration.
Your declaration
Q228. If I give wrong or incomplete information, or I do not report changes straight away, I may: • be prosecuted • need to pay a financial penalty • have my Pension Credit reduced or stopped • be paid too much Pension Credit and have to pay the money back.
Your declaration
Q229. For people filling in this form for someone else, please tell us about yourself below.
What to do now
Q230. Please make sure you have signed and dated the declaration.
What to do now
Q231. Please check: • that you are sending us all the original documents we have requested – for example, pension payslips • that you have answered all the questions on this form that apply to you and your partner, if you have one, and • that you have filled in form MI12, if we included one with this application form.
What to do now
Q232. Please tick which original documents you are sending to us. We will return all the documents to you. We will do our best to return them to you within 5 working days of receiving them.
Options: Proof of service charges; Proof of ground rent or ground annual; Proof of a private or works pension or any other pension - except a State Pension paid by the Department for Work and Pensions; Proof of money coming in
What to do now
Q233. Then send your forms and documents to us. Use the envelope that came with this form, if provided, which does not need a stamp. The form should then be sent to: Freepost DWP Pensions Site 8.
Changes to your personal circumstances
Q234. Please tell us about any changes to your personal circumstances. You must tell the Department for Work and Pensions straight away by using the number on page 1 of this form if there is a change in your circumstances or those of your partner (if you have one).
Changes to your personal circumstances
Q235. If you give wrong or incomplete information, or do not report changes straight away, you may: • not receive the full amount of Pension Credit you are entitled to • be paid too much and have to pay the money back • have your Pension Credit reduced or stopped • need to pay a financial penalty.
For office use only
Q236. For office use only. I have read back to the customer the entries I made on this form, based on the information they gave me. The customer agreed these were correct.
For office use only
Q237. Initial date of contact
For office use only
Q238. Interviewing officer's signature
For office use only
Q239. Date of application
For office use only
Q240. Customer's signature
For office use only
Q241. Date of entitlement
For office use only
Q242. Date of signature