Fillable Printable Carers Allowance Claim Form
Fillable Printable Carers Allowance Claim Form
Carers Allowance Claim Form
1
Title, for example
Mr, Mrs, Miss, Ms.
Surname or family name
Carer’s Allowance
Claim form
Please answer the questions on this form in BLOCK CAPITALS.
About you – the carer
All other names in full
All other surnames or family
names you have used or have
been known by
National Insurance (NI)
number
You can get this from your NI number card, letters about
benefits, payslips or form P60. If you do not tell us your NI
number, this could delay any benefit you may be entitled to.
Letters Numbers Letter
DS700 04/15
l Use this form to claim Carer’s Allowance.
l Please read the Notes that came with the
claim pack before you fill in the form.
l The form must be filled in by you, the carer,
not the person you look after.
l Please fill in this form with BLACK INK and
in CAPITALS.
l Please answer all of the questions and
send us all the documents we ask for.
l Contact us if you cannot fill in this form or
send us the documents we ask for.
Any benefit you may be entitled to may
be delayed.
This form is available in large print or braille. Please ring
0345 608 4321.
If you have speech or hearing difficulties, you can contact us
by textphone on 0345 604 5312.
Our textphone service does not receive messages from
mobile phones.
Calls to 0345 numbers cost no more than a standard
geographic call, and count towards any free or inclusive
minutes in your landline or mobile phone contract.
i
About you – the carer c
ontinued
2
Date of birth
/ /
Day Month Year
Postcode
Address
If you have speech or hearing difficulties and would like
us to contact you by textphone, tick here.
When do you want your
Carer’s Allowance claim
to start?
You must give us an exact
date or your claim may be
delayed.
If you do not fill in the
day, month and year, we
cannot accept your claim
and will return this form to
you.
/ /
Day Month Year
06 / 01 / 2014
Example of an exact date
Please make a note of this
date as we will ask you
about it again later.
For more information please read page 6 of the Notes.
i
About your Carer’s Allowance
Daytime phone number
where we can contact you
or leave a message. Please
include the dialling code.
Mobile number
If you live in Wales and
would like us to contact
you in Welsh, tick this box.
3
About you – the carer c
ontinued
What is your nationality?
For example, British.
If you have a current
passport, please give your
nationality as shown on
your passport.
Which country are you
living in now?
No
Yes
Were you present in
Great Britain throughout
the three years before
the date you are
claiming from?
By Great Britain we mean
England, Scotland or
Wales.
No
Yes
Is this the country that
you normally live in?
If No, which country do you normally live in?
If ‘No’ please give details below of any countries you have
lived in or visited, in the three years before the date you are
claiming from:
We may need to contact you for information about this.
Reason for being
there e.g.
home/holiday/work
To
/ // /
/ /
/ /
/ /
/ /
Country From
Was the
person you
look after
with you?
YES/NO
/ /
/ /
/ /
/ /
4
About you – the carer c
ontinued
No
Yes
Were you present in any
countries other than
Great Britain since the
date of claim?
If ‘Yes’ please give details of countries and dates:
No
Yes
Do you, or any member
of your family, receive
any benefits or pensions
from a country which is
not Great Britain?
No
Yes
Have you, or a member of
your family made a claim,
for any benefits or
pensions which has not
yet been decided, from a
country which is not
Great Britain?
No
Yes
Are you, or a member of
your family, working in
or paying insurance to,
another EEA state or
Switzerland?
If you have answered ‘Yes’ to any of the last 3 questions,
we will contact you for more information.
If there are other personal details you think we should know,
for example previous names and addresses, please tell us
about them on page 24 Other information.
5
About your partner
What is your marital or civil
partnership status?
single
married or civil partner
living with partner
separated
divorced or civil
partnership dissolved
widowed or surviving
civil partner
By partner we mean:
l a person you are married to or live with as if you are married, or
l a civil partner or a person you live with as if you are civil partners.
No
Yes
Please go to page 6.
Have you had a partner
living with you at any time
since the date you want to
claim from?
If you have separated from
your partner since the date
you want to claim Carer's
Allowance from, please tick
'Yes'.
No
Yes
Have you separated from
your partner since the date
you want to claim from?
Your partner’s title, for
example Mr, Mrs, Miss, Ms.
Their surname or
family name
Their other names in full
All other surnames or family
names they have used or
have been known by
Please tell us about your partner, if you have one.
Their National Insurance
(NI) number
You can get this from their NI number card, letters about
benefits, payslips or form P60. If you do not tell us their NI
number, this could delay any benefit you may be entitled to.
Letters Numbers Letter
Their date of birth
/ /
Day Month Year
What is their nationality?
For example, British.
6
About the care you provide
Their date of birth
Their address
You do not have to live at
the same address as the
person you look after.
Their daytime phone
number, including dialling
code. We will not give this
number to anyone else.
Title, for example
Mr, Mrs, Miss, Ms.
Their surname or family
name
Please tell us about the person you look after.
This will help us deal with your claim more quickly.
Their other names in full
Their National Insurance
(NI) number
/ /
Day Month Year
What relation is this person
to you?
If no relation, write None.
You can get this from their NI number card, letters about
benefits, payslips or form P60.
Children aged 16 and under have NI numbers. The child’s NI
number is the reference number on letters about Disability
Living Allowance for the child.
Postcode
Letters Numbers Letter
No
Yes
Does the person you look
after get Armed Forces
Independence Payment?
7
More about the care you provide
No
Yes
Use the table below to give us the exact
dates and times of the breaks.
Have you had any breaks in
looking after this person
since the date you want to
claim from?
By break we mean time when, for any reason, you spent
less than 35 hours a week caring for the person you look
after. This could be a period of time abroad, holiday, time
in a hospital or care facility by either you or the person
you care for.
Please put a tick in either of the last 2 columns if you or
the person you look after were getting medical or other
treatment as an in-patient in a hospital or similar place.
No
Yes
Do you spend 35 hours or
more each week caring for
the person you look after?
If you had more than three breaks, please tell us about them on page 24.
From
am/pm
To
am/pm
From
am/pm
To
am/pm
From
am/pm
To
am/pm
Date Time Reason for the break
You
4
Person
you look
after
By medical treatment we mean things like surgical treatment
or the administration of drugs and injections.
By other treatment we mean nursing services by professionally
trained staff. This includes things like:
l observation
l therapy
l support services
l advice and training in social and domestic skills.
It does not include straightforward care or attention by unqualified staff.
44
8
More about the care you provide c
ontinued
No
Yes
When did you start to look after this person?
Did you look after this
person for at least 35
hours each week before
the date you want to
claim from?
/ /
No
Yes
Use the table below to give us the exact
dates and times of the breaks.
Have you had any other
breaks in looking after this
person in the 26 weeks
before the date you want
to claim from?
No
Yes Where did they stay?
Was the person you look
after away from home in
any of the breaks you have
told us about?
Postcode
If you had more than three breaks, please tell us about them on page 24.
Please put a tick in either of the last 2 columns if you or
the person you look after were getting medical or other
treatment as an in-patient in a hospital or similar place.
From
am/pm
To
am/pm
From
am/pm
To
am/pm
From
am/pm
To
am/pm
Date Time Reason for the break
You
4
Person
you look
after
4
4
9
Statement on behalf of the person you look after
The person you look after needs to know if you are claiming
Carer's Allowance as this may affect some of their benefits.
There are 3 statements in this section. One of them must be
signed. The questions will help you decide who needs to sign.
Notes for the person being looked after
If you get a severe disability premium with your income-based Jobseeker’s
Allowance, Income Support, income-related Employment and Support Allowance
or Housing Benefit, you may no longer get that premium if we pay Carer’s
Allowance to your carer.
If your Pension Credit includes an extra amount for severe disability, you may no
longer get that extra amount if we pay Carer’s Allowance to your carer.
For more information about this, contact the office that deals with your benefit or
entitlement.
This could also affect any reduction in Council Tax you may be entitled to. To find
out more about it, please contact the Local Authority.
If we pay Carer’s Allowance to your carer, your Personal Independence Payment,
Disability Living Allowance, Attendance Allowance, Constant Attendance
Allowance or Armed Forces Independence Payment will not be affected.
No
Yes
If the person you look after is unable to sign
Statement 1 because of a health condition, a
disability, or because they are under 16, someone
who acts for them can sign on their behalf. Please
go to Statement 2 on page 10.
Please ask them to read the notes below, then to
sign Statement 1 below. Then go to page 12.
Can the person you look
after sign a statement?
Statement 1
I understand that the carer named on page 1 is making a claim for Carer's
Allowance and that this may affect some of my benefits.
I understand that you will look at details of my claim for Personal Independence
Payment, Disability Living Allowance, Attendance Allowance, Constant
Attendance Allowance or Armed Forces Independence Payment as part of their
claim for Carer’s Allowance.
Please tick one of the following boxes.
I can confirm that the carer named on page 1
looks after me for at least 35 hours a week.
I cannot confirm that the carer named on page 1
looks after me for at least 35 hours a week.
Date / /
Signature
Statement 1 continues on page 10.
If you have ticked this box,
please tell us why on page 10.
10
Statement on behalf of the person you look after c
ontinued
If you cannot confirm that
the carer named on page 1
looks after you for at least
35 hours a week, please tell
us why.
Statement 2
Please tick one of the following boxes.
Date / /
Signature
I am acting for benefit purposes for the person being looked after,
and I am their
parent or guardian
attorney
appointee
judicial factor
deputy
curator bonis.
I understand that my claim for Carer's Allowance may affect some
of their benefits.
I understand that you will look at details of their claim for Personal
Independence Payment, Disability Living Allowance, Attendance
Allowance, Constant Attendance Allowance or Armed Forces
Independence Payment as part of my claim for Carer’s Allowance.
No
Yes
Please go to Statement 3 on page 11.
Please read and sign the statement below. Then go
to page 12.
Do you act for the person
you look after?
Now return this form to your carer.
11
Statement on behalf of the person you look after c
ontinued
Statement 3
Date
/ /
Signature
Please tick one of the following boxes.
If you cannot confirm that
the carer named on
page 1 looks after the
person being cared for, for
at least 35 hours a week,
please tell us why.
Please tick one of the following boxes.
I can confirm that the carer named on page 1
looks after the person being cared for,
for at least 35 hours a week.
I cannot confirm that the carer named on page 1
looks after the person being cared for,
for at least 35 hours a week.
I am acting for benefit purposes for the person being looked after, and I am their
parent or guardian
attorney
appointee
judicial factor
deputy
curator bonis.
I understand that this claim for Carer's Allowance may affect some of their benefits.
I understand that you will look at details of their claim for Personal Independence
Payment, Disability Living Allowance, Attendance Allowance, Constant Attendance
Allowance or Armed Forces Independence Payment as part of this claim for Carer’s
Allowance.
Full name
No
Yes
Please go to page 12.
Please ask them to read and sign the statement below.
Then go to page 12.
Does someone else act for
the person you look after?
