Form BB1 11/25
Part 1: About you
Q1. National Insurance (NI) number
Guidance: You can find this on your National Insurance (NI) numbercard, letters from the Department for Work and Pensions or payslips.
Part 1: About you
Q2. Have you ever had one or used one at any time?
Options: Yes; No
Part 1: About you
Q3. Surname or family name Mr/Mrs/Miss/Ms
Part 1: About you
Q4. All other names, in full
Guidance: Please include maiden name, all former married or civil partnership names and all changes of family name where appropriate.
Part 1: About you
Q5. Address
Part 1: About you
Q6. Postcode
Part 1: About you
Q7. Home phone number Code Number
Part 1: About you
Q8. Mobile phone number
Part 1: About you
Q9. Email address where we can contact you
Guidance: Please confirm if this email address is personal private secure
Part 1: About you
Q10. Date of birth / /
Guidance: Please send us your original birth certificate, if you have it. Do not send us a photocopy. But if you do not have your birth certificate, do not delay sending in this claim form. If you prefer, you can take your birth certificate to your Jobcentre Plus office. Take this form as well. They will sign this form to show that they have seen your certificate.
Part 1: About you
Q11. Are you sending your birth certificate with this form?
Options: Yes; No
Guidance: We will send your birth certificate back to you as soon as we can.
Part 1: About you
Q12. What was the date of your marriage or civil partnership?
Guidance: If you converted or changed your civil partnership into a marriage or married your civil partner, enter the date your marriage is treated as starting on.
Part 1: About you
Q13. Are you sending your marriage or civil partnership certificate with this form?
Options: Yes; No
Guidance: We will send your marriage or civil partnership certificate back to you as soon as we can.
Part 1: About you
Q14. Under what law/religion was the ceremony conducted?
Part 1: About you
Q15. Please tell us the country where your marriage or civil partnership took place.
Part 1: About you
Q16. Did your marriage end in divorce or has your civil partnership been dissolved?
Options: Yes; No
Part 1: About you
Q17. Are you legally separated?
Options: Yes; No
Part 1: About you
Q18. Are you, or have you been living with someone else as if you were married to them, or as if you are civil partners?
Options: Yes; No
Guidance: Please tell us about this at Part 6.
Part 2: About your spouse or civil partner
Q19. Your spouse or civil partner’s National Insurance (NI) number
Part 2: About your spouse or civil partner
Q20. Your spouse or civil partner’s Mr/Mrs/Miss/Ms surname
Part 2: About your spouse or civil partner
Q21. Your spouse or civil partner’s other names
Part 2: About your spouse or civil partner
Q22. Address if it was different from your address. If you do not know their address, write Not known.
Part 2: About your spouse or civil partner
Q23. Postcode
Part 2: About your spouse or civil partner
Q24. Your spouse or civil partner’s date of birth / /
Part 2: About your spouse or civil partner
Q25. What date did your spouse or civil partner die?
Guidance: Please send us the Certificate of Registration of Death if you have not already sent it to us. You can get this from the registrar in Great Britain only. If you have an interim death certificate or a letter from the coroner confirming the death, please send it to us.
Part 2: About your spouse or civil partner
Q26. Did your spouse or civil partner die more than 3 months ago?
Options: Yes; No
Guidance: If you need more space, please use Part 6.
Part 2: About your spouse or civil partner
Q27. Were they getting a State Pension or any other benefits?
Options: Yes; No
Guidance: Please say which benefits.
Part 2: About your spouse or civil partner
Q28. Did they pay NI contributions during the 2 years up to 5 April before they died?
Options: Yes; No
Guidance: Please tell us about this.
Part 2: About your spouse or civil partner
Q29. Did they pay these contributions through an employer?
Options: Yes; No
Guidance: Please tell us about any employers they had during this period.
Part 2: About your spouse or civil partner
Q30. Employer 1 Employer 2 Employer’s name and address
Guidance: If you know that pay is dealt with at a different address, please give us this address and phone number.
Part 2: About your spouse or civil partner
Q31. Clock or payroll number
Guidance: If not known, tell us their job or department.
Part 2: About your spouse or civil partner
Q32. Date they started work for / / / / this employer
Part 2: About your spouse or civil partner
Q33. Date they stopped work for / / / / this employer
Part 2: About your spouse or civil partner
Q34. Were they self-employed?
Options: Yes; No
Part 2: About your spouse or civil partner
Q35. Were they a member of HM Forces when they died?
Options: Yes; No
Part 2: About your spouse or civil partner
Q36. Were they getting a War Pension when they died?
Options: Yes; No
Guidance: Please tell us their reference number. This is on any letters about their War Pension.
Part 2: About your spouse or civil partner
Q37. Do you think your spouse or civil partner died because of an accident at work, or because of a disease or illness connected with their work?
Options: Yes; No
Guidance: May we get medical reports from their doctor and any hospital, if we need them?
Part 2: About your spouse or civil partner
Q38. Did your spouse or civil partner ever live outside the UK?
Options: Yes; No
Guidance: Please go to Part 3.
Part 2: About your spouse or civil partner
Q39. Country 1 Country 2 Which country or crown dependency did they live in? If they lived in the Isle of Man, tell us here.
Part 2: About your spouse or civil partner
Q40. When did they live there? From / / To / / From / / To / /
Part 2: About your spouse or civil partner
Q41. Did they pay into the social security scheme of the country they lived in?
Options: Yes; No; Do not know
Part 2: About your spouse or civil partner
Q42. What was their social security reference number?
Part 3: About children
Q43. Are you expecting a child with your late spouse or civil partner?
Options: Yes; No
Guidance: If you are, you may be able to get extra benefit when the baby is born.
Part 3: About children
Q44. What date is the baby expected? / /
Part 3: About children
Q45. Are you entitled to any Child Benefit?
Options: Yes; No
Part 3: About children
Q46. Tell us the Child Benefit reference number.
Part 3: About children
Q47. How much do you get each week? £ each week
Part 3: About children
Q48. Are you waiting to hear if you can get Child Benefit?
Options: Yes; No
Part 3: About children
Q49. When your spouse or civil partner died, were they getting any Child Benefit for any children?
Options: Yes; No
Part 3: About children
Q50. Tell us the Child Benefit reference number.
Part 3: About children
Q51. How much did they get each week? £ each week
Part 3: About children
Q52. Do you have any children or qualifying young persons living permanently in your household who are dependent on you?
Options: Yes; No
Guidance: We use child to mean a person aged under 16 and qualifying young person to mean a person aged 16, 17, 18 or 19.
Part 3: About children
Q53. 1st child Child’s surname
Part 3: About children
Q54. Child’s other names
Part 3: About children
Q55. Child’s date of birth / /
Part 3: About children
Q56. What relation, if any, are you to the child?
Part 3: About children
Q57. What relation, if any, was your spouse or civil partner to the child?
Part 3: About children
Q58. 2nd child Child’s surname
Part 3: About children
Q59. Child’s other names
Part 3: About children
Q60. Child’s date of birth / /
Part 3: About children
Q61. What relation, if any, are you to the child?
Part 3: About children
Q62. What relation, if any, was your spouse or civil partner to the child?
Part 3: About children
Q63. 3rd child Child’s surname
Part 3: About children
Q64. Child’s other names
Part 3: About children
Q65. Child’s date of birth / /
Part 3: About children
Q66. What relation, if any, are you to the child?
Part 3: About children
Q67. What relation, if any, was your spouse or civil partner to the child?
Part 3: About children
Q68. 4th child Child’s surname
Part 3: About children
Q69. Child’s other names
Part 3: About children
Q70. Child’s date of birth / /
Part 3: About children
Q71. What relation, if any, are you to the child?
Part 3: About children
Q72. What relation, if any, was your spouse or civil partner to the child?
Part 3: About children
Q73. If you want to tell us about more than 4 children, please tell us about them in Part 6.
Part 3: About children
Q74. If a child is living with another person Which child is living with another person?
Part 3: About children
Q75. What relation, if any, is this other person to the child?
Part 3: About children
Q76. How much do you send each week £ each week for the child?
Part 3: About children
Q77. If a child is in care Which child is in care?
Part 3: About children
Q78. What is the name and address of the local authority caring for the child?
Part 3: About children
Q79. Postcode
Part 3: About children
Q80. How much do you send each week £ each week for the child?
Part 3: About children
Q81. Have you told us about any children who you are not a parent of?
Options: Yes; No
Guidance: We use parent to include step-parents, parents by legal adoption and fathers and mothers of illegitimate children. If you need to tell us about more than one child, use the space in Part 6.
Part 3: About children
Q82. Name of the child.
Part 3: About children
Q83. Does one of their parents live at the same address as you?
Options: Yes; No
Part 3: About children
Q84. What is their name?
Part 3: About children
Q85. Are you, or anyone else, entitled to any benefit or allowance for any of the children you have told us about?
Options: Yes; No
Guidance: For example Guardian’s Allowance. But tick No if you are just entitled to Child Benefit.
Part 3: About children
Q86. Benefit or allowance 1 Benefit or allowance 2 Name of the benefit or allowance
Part 3: About children
Q87. Address of the office it comes from
Part 3: About children
Q88. Name of the child it is for
Part 3: About children
Q89. Who gets the benefit or allowance? You Someone else Please say who.
Part 3: About children
Q90. Benefit reference number This is on any letters about the benefit.
Part 3: About children
Q91. Are any of the children you have told us about getting any benefit or allowance?
Options: Yes; No
Part 3: About children
Q92. Benefit or allowance 1 Benefit or allowance 2 Name of the benefit or allowance
Part 3: About children
Q93. Address of the office it comes from
Part 3: About children
Q94. Name of the child it is for
Part 3: About children
Q95. Benefit reference number This is on any letters about the benefit.
Part 4: About other benefits
Q96. Have you claimed bereavement benefits or Widow’s Benefit before?
Options: Yes; No
Part 4: About other benefits
Q97. Did you get bereavement benefits or Widow’s Benefit?
Options: Yes; No
Guidance: Tick Yes if you claimed but were turned down.
Part 4: About other benefits
Q98. Are you getting any of these benefits or entitlements?
Options: Yes; No
Guidance: Tick Yes if you are waiting to hear about a benefit.
Part 4: About other benefits
Q99. Name of benefit Reference number Even if the benefit or entitlement is not listed here, tell us about it anyway. We will contact you if we need more information.
Guidance: This is on any letters we have sent you about the benefit.
Part 5: How we pay you
Q100. How often do you want us to pay your benefit?
Options: Every 2 weeks; Every 4 weeks; Every 13 weeks
Part 5: How we pay you
Q101. About the account you want to use Name of the account holder
Guidance: Please write the name of the account holder exactly as it is shown on the chequebook or statement.
Part 5: How we pay you
Q102. Full name of bank or building society Sort code Please tell us all 6 numbers, for example 12-34-56.
Part 5: How we pay you
Q103. Account number Most account numbers are 8 numbers long. If your account number has fewer than 10 numbers, please fill in the numbers from the left.
Part 5: How we pay you
Q104. 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 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.
Part 5: How we pay you
Q105. You may get other benefits and entitlements we do not pay into an account. If you want us to pay them into the account above, please tick the box.
Part 6: Other information
Q106. Please read carefully the notes that came with this form. 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. Make sure you put your full name and National Insurance (NI) number on each sheet of paper, and sign and date each sheet that you use.
Part 7: Declaration
Q107. I declare that I am a widow, widower or surviving civil partner of the person named in Part 2 of this form.
Guidance: I understand that if I give false or incomplete information or fail to report all changes in my circumstances which may affect my entitlement promptly, I may be liable to prosecution or face a financial penalty. I declare that I have read and understand the notes which came with this form and that I must telephone or write to the office that pays my benefit to report any change in my circumstances. I declare that the information in my claim is complete and correct.
Part 7: Declaration
Q108. Signature Date / /