Form AA1
Special rules
Q1. Are you claiming under the special rules?
Options: No; Yes
Guidance: To find out more about special rules, please read page 7 of the information booklet.
About you
Q2. Surname or family name
About you
Q3. National Insurance (NI) number
About you
Q4. Date of birth
Guidance: DD/MM/YYYY
About you
Q5. Sex
Options: Female; Male
About you
Q6. The full address where you permanently live
About you
Q7. Your contact details
Guidance: Mobile phone number, if you have one. Daytime phone number, if different. Please include dialling code. All other names in full.
About you
Q8. What is your nationality?
Guidance: For example, Mr, Mrs Miss, Ms. If you are a Swiss or a European Economic Area (EEA) national, were you living in the United Kingdom (UK) before 1 January 2021?
About you
Q9. Do you normally live in Great Britain?
Options: No; Yes; Do not know
Guidance: Great Britain is England, Scotland and Wales. For more information please read page 8 of the notes.
About you
Q10. Have you been abroad for more than 4 weeks at a time in the last 3 years?
Options: No; Yes; Do not know
Guidance: Abroad means out of Great Britain.
About you
Q11. Are you, your wife, husband or civil partner getting any pensions or benefits from an EEA state or Switzerland?
Options: No; Yes; Do not know
About you
Q12. Are you, your wife, husband or civil partner working in or paying insurance to an EEA state or Switzerland?
Options: No; Yes; Do not know
Guidance: By insurance we mean connected to from work, like UK National Insurance.
About you
Q13. Have you moved from Scotland to live in England or Wales?
Options: No; Yes
About you
Q14. Are you getting or have you made a claim for Pension Age Disability Payment?
Options: No; Yes
Signing the form for someone else
Q15. Are you signing the form for someone else?
Options: No; Yes
About your illnesses or disabilities and the treatment or help you get
Q16. What illnesses or disabilities do you have?
Guidance: Name of illness or disability. How long have you had it (or both). What medicines or treatments have you been prescribed for this illness or disability? What is the dosage and how often do you take each of the medicines or treatment?
About your illnesses or disabilities and the treatment or help you get
Q17. Apart from your GP, in the last 12 months have you seen anyone about your illnesses or disabilities?
Options: No; Yes
Guidance: For example, a hospital doctor or consultant, district or specialist nurse, community psychiatric nurse, occupational therapist, physiotherapist, audiologist or social worker.
About your illnesses or disabilities and the treatment or help you get
Q18. Does anyone else help you because of your illnesses or disabilities?
Options: No; Yes
Guidance: For example, a carer, support worker, nurse, friend, neighbour or family member.
About your illnesses or disabilities and the treatment or help you get
Q19. About your GP
Guidance: The GP only gives details of medical fact, they do not decide if you can get Attendance Allowance.
About your illnesses or disabilities and the treatment or help you get
Q20. Do you agree to DWP contacting the people or organisations described?
Options: No; Yes
Guidance: We may want to contact your GP, or the people or organisations involved with you, for information about your claim. This may include medical information. You do not have to agree to us contacting these people or organisations, but if you do not agree, we may be unable to make sure you qualify for the benefit you are claiming.
About your illnesses or disabilities and the treatment or help you get
Q21. Do you have any reports about your illnesses or disabilities?
Options: No; Yes
Guidance: These may be from a person who treats you, for example, an occupational therapist, hospital doctor or counsellor. It may be an assessment report, a care plan or something like this?
About your illnesses or disabilities and the treatment or help you get
Q22. Are you on a waiting list for surgery?
Options: No; Yes
About your illnesses or disabilities and the treatment or help you get
Q23. Have you had any tests for your illnesses or disabilities?
Options: No; Yes
Guidance: For example, a peak flow, a treadmill exercise, a hearing or sight test or something else.
About your illnesses or disabilities and the treatment or help you get
Q24. What type of accommodation do you live in?
Options: Upstairs; Downstairs; Other
Guidance: For example, you may live in a house, bungalow, flat, supported housing, residential care home, nursing home or somewhere else.
About your illnesses or disabilities and the treatment or help you get
Q25. Where is the toilet in your home?
Options: Upstairs; Downstairs; Other
Guidance: Tell us where.
About your illnesses or disabilities and the treatment or help you get
Q26. Where do you sleep in your home?
About your illnesses or disabilities and the treatment or help you get
Q27. What aids or adaptations do you use?
Guidance: Put a tick in the second box against those that have been prescribed by a health care professional, for example, an occupational therapist. If you have difficulty using any aids or adaptations or you need help from another person to use them, please tell us.
About your illnesses or disabilities and the treatment or help you get
Q28. Please tell us the date you started to need the help you have told us about in this claim form.
Guidance: If you cannot remember the exact date, tell us roughly when this was.
About your illnesses or disabilities and the treatment or help you get
Q29. Do you usually have difficulty or do you need help getting out of bed in the morning or getting into bed at night?
Options: No; Yes
Guidance: I have difficulty: getting into bed, getting out of bed. I need help: getting into bed, getting out of bed.
About your illnesses or disabilities and the treatment or help you get
Q30. Do you usually have difficulty or do you need help with your toilet needs?
Options: No; Yes
Guidance: This means things like getting to the toilet, or using the toilet, commode, bedpan or bottle. It also means using or changing incontinence aids, or a catheter or cleaning yourself.
About your illnesses or disabilities and the treatment or help you get
Q31. Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?
Options: No; Yes
Guidance: This means things like getting into or out of the bath or shower, checking your appearance or looking after your personal hygiene. Personal hygiene includes things like cleaning your teeth, washing your hair, shaving or something like this.
About your illnesses or disabilities and the treatment or help you get
Q32. Do you usually have difficulty or do you need help with dressing or undressing?
Options: No; Yes
About your illnesses or disabilities and the treatment or help you get
Q33. Do you usually have difficulty or do you need help with moving around indoors?
Options: No; Yes
Guidance: By indoors we mean anywhere inside, not just the place where you live.
About your illnesses or disabilities and the treatment or help you get
Q34. Do you fall or stumble because of your illnesses or disabilities?
Options: No; Yes
Guidance: For example, you may fall or stumble because you have weak muscles, stiff joints or your knee gives way, or you may have problems with your sight, or you may faint, feel dizzy, blackout or have a fit.
About your illnesses or disabilities and the treatment or help you get
Q35. Do you usually have difficulty or do you need help with cutting up food, eating or drinking?
Options: No; Yes
Guidance: This means things like getting food or drink into your mouth or identifying food on your plate.
About your illnesses or disabilities and the treatment or help you get
Q36. Do you usually have difficulty or do you need help with taking your medicines or with your medical treatment?
Options: No; Yes
Guidance: This means things like injections, an inhaler, eye drops, physiotherapy, oxygen therapy, speech therapy, monitoring treatment, coping with side effects, and help from mental-health services. It includes handling medicine and understanding which medicines to take, how much to take and when to take them.
About your illnesses or disabilities and the treatment or help you get
Q37. Do you usually need help from another person to communicate with other people?
Options: No; Yes
Guidance: For example, you may have a mental-health problem, learning disability, sight, hearing or speech difficulty and need help to communicate. Please answer as if using your normal aids, such as glasses or a hearing aid.
About your illnesses or disabilities and the treatment or help you get
Q38. How many days a week do you have difficulty or need help with the care needs you have told us about on questions 28 to 37?
About your illnesses or disabilities and the treatment or help you get
Q39. Do you usually need help from another person to actively take part in hobbies, interests, social or religious activities?
Options: No; Yes
Guidance: We need this information because we can take into account the help you need or would need to take part in these activities, as well as the other help you need during the day.
About your illnesses or disabilities and the treatment or help you get
Q40. Do you usually need someone to keep an eye on you?
Options: No; Yes
Guidance: For example, you may have a mental-health problem, learning disability, sight, hearing or speech difficulty and need supervision. I may have fits, dizzy spells or blackouts.
About your illnesses or disabilities and the treatment or help you get
Q41. How many days a week do you need someone to keep an eye on you?
About your illnesses or disabilities and the treatment or help you get
Q42. Do you usually have difficulty or need help during the night?
Options: No; Yes
Guidance: This means things like settling, getting into position to sleep, being propped up or getting your bedclothes back on the bed if they fall off, getting to the toilet, using the toilet, using a commode, bedpan or bottle, getting to and taking the tablets or medicines prescribed for you and having any treatment or therapy.
About your illnesses or disabilities and the treatment or help you get
Q43. How many nights a week do you have difficulty or need help with your care needs?
About your illnesses or disabilities and the treatment or help you get
Q44. Do you usually need someone to watch over you?
Options: No; Yes
Guidance: For example, you may have a mental-health problem, learning disability, sight, hearing or speech difficulty and need another person to be awake to watch over you.
About your illnesses or disabilities and the treatment or help you get
Q45. How many nights a week do you need someone to watch over you?
About your illnesses or disabilities and the treatment or help you get
Q46. Please tell us anything else you think we should know about the difficulty you have or the help you need.
Guidance: If you need some more space to tell us about the help you need or the difficulty you have with your care needs, please continue at question 63 Extra information.
About time spent in hospital, a care home or a similar place
Q47. Are you in hospital, a care home or similar place now?
Options: No; Yes
Guidance: For example, a residential care home, nursing home, hospice or similar place.
About time spent in hospital, a care home or a similar place
Q48. Have you come out of hospital, a care home or similar place in the past six weeks?
Options: No; Yes
About time spent in hospital, a care home or a similar place
Q49. Constant Attendance Allowance
Options: War Pension Constant Attendance Allowance; Industrial Injuries Disablement Benefit Constant Attendance Allowance
How we pay you
Q50. Name of the account holder
Guidance: Exactly as it is shown on the chequebook or statement.
How we pay you
Q51. Name of the bank or building society
How we pay you
Q52. Sort code
Guidance: Tell us all 6 numbers, for example 12-34-56.
How we pay you
Q53. Account number
Guidance: Most account numbers are 8 numbers long. If your account number has fewer than 10 numbers, please fill in the numbers from the left.
How we pay you
Q54. Building society roll or reference number
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 may be up to 18 characters long. If you are not sure if the account has a roll or reference number, ask the building society.
Statement from someone who knows you
Q55. How often do you see the person this form is about?
Statement from someone who knows you
Q56. What are their illnesses and disabilities and how they are affected by them?
Statement from someone who knows you
Q57. What is your job, profession or relationship to the person this form is about?
Statement from someone who knows you
Q58. What is your name?
Statement from someone who knows you
Q59. What is your address?
Statement from someone who knows you
Q60. What is your daytime phone number?
Guidance: This is where we can contact you or leave a message.
Statement from someone who knows you
Q61. Your signature
Statement from someone who knows you
Q62. Date
Extra information
Q63. Please tell us anything else you think we should know about your claim.
Guidance: Continue on a separate piece of paper, if necessary. Remember to write your name and National Insurance number at the top of each page.
Declaration
Q64. Signature
Guidance: By submitting this claim you agree that the information you have given is complete and correct; while you are receiving Attendance Allowance, you will report changes to your circumstances straight away by calling 0800 731 0122. If you give wrong or incomplete information, or you do not report changes straight away, you may: • be prosecuted • need to pay a financial penalty • have your Attendance Allowance reduced or stopped • be paid too much Attendance Allowance and have to pay the money back. If we pay you less than we should, we may pay you the money that we owe you.
What to do now
Q65. Please list all the documents you are sending with this claim form.
Guidance: For example, a prescription list, a certificate of vision impairment, a medical report, passport or a care plan.