Form PC1H
About this form
Q1. Please fill in this form if your money, savings and investments add up to more than £10,000.
About this form
Q2. Answer the questions on this form and then read and sign the declaration. You will need to provide documents to prove the amount of money, savings or investments you have.
About this form
Q3. Please return this form with your Pension Credit application form.
Help with your application and the documents we need
Q4. If you need help to fill in this form you can: • phone The Pension Credit claim line on 0 8 0 0 9 9 1 2 3 4 • ask a friend or advice centre to help you.
Help with your application and the documents we need
Q5. If you cannot fill in the form because you do not have the information, or you cannot provide us with the documents we have asked for, please contact us as soon as possible.
Help with your application and the documents we need
Q6. If you are worried about sending us original documents, you can send them by recorded delivery or by registered post.
The proof you need to send us
Q7. Please tick which original documents you are sending us: bank statement, savings account book, unit trust certificate, letter of ownership, proof of other investments – for example ISAs, PEPs, TOISAs.
Options: bank statement; savings account book; unit trust certificate; letter of ownership; proof of other investments – for example ISAs, PEPs, TOISAs
Guidance: Please make sure any savings account books have been updated before you send them, as this will save time. Any documents you send us must be originals, not photocopies.
About money you have, including savings and investments
Q8. Money in a bank current account National Savings Certificate 2 £ £ Certificate issue number
About money you have, including savings and investments
Q9. Money in any other bank account £
About money you have, including savings and investments
Q10. Money in a building society current account £
About money you have, including savings and investments
Q11. Money in any other building society account £
About money you have, including savings and investments
Q12. Money in a Post Office® account £
About money you have, including savings and investments
Q13. Cash saved for something £
About money you have, including savings and investments
Q14. National Savings Certificates National Savings Certificate 1 £ £ Certificate issue number
About money you have, including savings and investments
Q15. Premium Bonds £
About money you have, including savings and investments
Q16. Income bonds or capital bonds £
About money you have, including savings and investments
Q17. Unit trusts, ISAs, PEPs, TOISAs or other investments £
About money you have, including savings and investments
Q18. Money or property held in trust £
About money you have, including savings and investments
Q19. Shares Shares 1 Approximate value £ Number of units held Name of the company the shares are held in
About money you have, including savings and investments
Q20. Any other money or investments £ Type of other money or investment For example, ordinary shares, B shares or preference shares.
About money you have, including savings and investments
Q21. Total savings and investments £
More about your savings
Q22. Money from an insurance policy for repair or replacement of your home or personal possessions £ What date did you get this?
More about your savings
Q23. Money from the sale of your home to be used to buy a new home £ What date did you get this?
More about your savings
Q24. Money paid to you to carry out essential repairs to your home £ What date did you get this?
More about your savings
Q25. A Social Fund payment or arrears of: • Adult Disability Payment Eileen or Skipton Trusts, or London Bombings Relief Charitable Fund? • Attendance Allowance • Child Benefit • Child Tax Credit • Constant Attendance Allowance • Disability Living Allowance • Exceptionally Severe Disablement Allowance • Housing Benefit • Income Support • Income-related Employment and Support Allowance • Income-based Jobseeker’s Allowance • Pension Age Disability Payment • Pension Credit • Personal Independence Payment • Scottish Adult Disability Living Allowance • Universal Credit, or a payment from Housing Related Support Services – this may be from the Supporting People Programme.
Options: Adult Disability Payment Eileen or Skipton Trusts, or London Bombings Relief Charitable Fund?; Attendance Allowance; Child Benefit; Child Tax Credit; Constant Attendance Allowance; Disability Living Allowance; Exceptionally Severe Disablement Allowance; Housing Benefit; Income Support; Income-related Employment and Support Allowance; Income-based Jobseeker’s Allowance; Pension Age Disability Payment; Pension Credit; Personal Independence Payment; Scottish Adult Disability Living Allowance; Universal Credit, or a payment from Housing Related Support Services – this may be from the Supporting People Programme.
More about your savings
Q26. Have you or your partner had a compensation payment for a personal injury? No Yes How much did you get?
Options: No; Yes
More about your savings
Q27. Have you or your partner had a payment from the vCJD, MacFarlane, London Bombings Relief Charitable Fund? No Yes How much did you get? What date did you get this?
Options: No; Yes
More about your savings
Q28. Have you or your partner had a lump sum payment as a result of putting off claiming State Pension? No Yes How much did you get? What date did you get this?
Options: No; Yes
More about your savings
Q29. Have you or your partner had a special payment because of atrocities that happened during the Second World War or from the Armed Forces Compensation Scheme? No Yes How much did you get?
Options: No; Yes
More about your savings
Q30. Have you or your partner had a special payment made to Far Eastern Prisoners of War or internees? No Yes How much did you get?
Options: No; Yes
Any further information
Q31. Tell us anything else you think we should know. If the date you are applying from is in the past, use this space to tell us if the details have changed since that date and when they changed.
Declaration
Q32. Your signature Date of signature
Declaration
Q33. I understand that if I knowingly give information that is incorrect or incomplete, my benefit may be stopped and I may be liable to prosecution or other action. I declare that the information I have given on this form is correct and complete as far as I know and believe and I have included all my income and savings.