Form CC1
About you, the carer
Q1. Title
Guidance: For example, Mr, Mrs Miss, Ms or other
About you, the carer
Q2. Surname or family name
About you, the carer
Q3. All other names in full
Guidance: Include maiden names, all former married names and all changes of surname or family name.
About you, the carer
Q4. Any other surnames you have been known by or are using now
About you, the carer
Q5. National Insurance (NI) number
Guidance: You can get this from your National Insurance number card, letters about benefits, payslips or form P60.
About you, the carer
Q6. Date of birth
About you, the carer
Q7. Address
About you, the carer
Q8. Daytime phone number
Guidance: Where we can contact you or leave a message. Please include the area code.
About you, the carer
Q9. Mobile phone number
About you, the carer
Q10. When do you want your Carer’s Credit to start?
Guidance: If you do not tell us a date, your application may be delayed.
About you, the carer
Q11. Do you normally live in Great Britain?
Options: Yes; No
Guidance: By Great Britain we mean England, Scotland and Wales. Tick Yes if you are part of a family living overseas with HM forces.
About you, the carer
Q12. Where do you normally live?
About you, the carer
Q13. Have you been in prison or legal custody since the date you want your Carer’s Credit to start from?
Options: Yes; No
Guidance: No Go to question 15
About you, the carer
Q14. When were you in prison or legal custody?
Guidance: From To
About the care you provide
Q15. Have you looked after one or more people, for a total of 20 hours or more a week, since the date you want to apply from?
Options: Yes; No
Guidance: If you have looked after one or more people for only some weeks since this date, still tick Yes. To find out more, see page 3 of the CC1 notes. You will only be able to get Carer’s Credit if you have looked after one or more people for at least 20 hours a week.
About the care you provide
Q16. Title
Guidance: For example, Mr, Mrs Miss, Ms or other
About the care you provide
Q17. Surname or family name
About the care you provide
Q18. All other names in full
About the care you provide
Q19. Their date of birth
About the care you provide
Q20. Their address
Guidance: You do not have to live at the same address as the person you look after.
About the care you provide
Q21. Their National Insurance (NI) number
About the care you provide
Q22. How many hours a week do you look after this person?
About the care you provide
Q23. Does this person get: • Personal Independence Payment at the standard or enhanced rate of the Daily Living Component, or • Adult Disability Payment at the standard or enhanced rate of the Daily Living Component, or • Disability Living Allowance care component at the middle rate or the highest rate, or • Scottish Adult Disability Living Allowance care component at the middle rate or the highest rate, or • Child Disability Payment care component at the middle or highest rate, or • Attendance Allowance, or • Pension Age Disability Payment, or • Constant Attendance Allowance, or • Armed Forces Independence Payment?
Options: Yes; No
Guidance: No You need to fill in a Care Certificate for this person. Yes You do not need to fill in a Care Certificate for this person. See the notes for more information about Care Certificates.
About the care you provide
Q24. Have you had a break of more than 12 weeks in looking after this person, since the date you want your Carer’s Credit to start?
Options: Yes; No
Guidance: No Go to question 25. Yes When did you stop looking after this person? When did you start looking after this person again? If you had any other breaks of more than 12 weeks, please tell us about them in the space at question 35.
About the care you provide
Q25. Do you look after more than one person?
Options: Yes; No
Guidance: No Go to Declaration. Yes Please tell us about one other person starting at question 26.
About the care you provide
Q26. Title
Guidance: For example, Mr, Mrs Miss, Ms or other
About the care you provide
Q27. Surname or family name
About the care you provide
Q28. All other names in full
About the care you provide
Q29. Their date of birth
About the care you provide
Q30. Their address
Guidance: You do not have to live at the same address as the person you look after.
About the care you provide
Q31. Their National Insurance (NI) number
About the care you provide
Q32. How many hours a week do you look after this person?
About the care you provide
Q33. Does this person get: • Personal Independence Payment at the standard or enhanced rate of the Daily Living Component, or • Adult Disability Payment at the standard or enhanced rate of the Daily Living Component, or • Disability Living Allowance care component at the middle rate or the highest rate, or • Scottish Adult Disability Living Allowance care component at the middle rate or the highest rate, or • Child Disability Payment care component at the middle or highest rate, or • Attendance Allowance, or • Pension Age Disability Payment, or • Constant Attendance Allowance, or • Armed Forces Independence Payment?
Options: Yes; No
Guidance: No You need to fill in a Care Certificate for this person. Yes You do not need to fill in a Care Certificate for this person. See the notes for more information about Care Certificates.
About the care you provide
Q34. Have you had a break of more than 12 weeks in looking after this person, since the date you want your Carer’s Credit to start?
Options: Yes; No
Guidance: No Go to question 35. Yes When did you stop looking after this person? When did you start looking after this person again? If you had any other breaks of more than 12 weeks, please tell us about them in the space at question 35.
Other information
Q35. Use this space to tell us anything else you think we might need to know.
Guidance: If there is not enough space, please use a separate sheet of paper.
Declaration
Q36. Signature
Declaration
Q37. Date