Fillable Printable Carer's Allowance Claim Form for People Who are Getting State Pension
Fillable Printable Carer's Allowance Claim Form for People Who are Getting State Pension
Carer's Allowance Claim Form for People Who are Getting State Pension
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
Letters Numbers Letter
DS700(SP) 04/15
Only use this form to claim Carer’s Allowance if you are
getting State Pension
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,
thecarer, not the person you look after.
l Please fill in this form with BLACK INK and
in CAPITALS.
l Please answer all the questions.
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.
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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?
/ /
Day Month Year
For more information please read page 14 of the Notes.
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About your Carer’s Allowance
Daytime phone number
Mobile number
If you live in Wales and
would like us to contact you
in Welsh, tick this box.
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
3
About you – the carer c
ontinued
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?
No
Yes
Were you present in any
countries other than
Great Britain since the
date of claim?
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 4 questions,
we will contact you for more information.
What is your nationality?
For example, British.
If you have a current
passport, please give your
nationality as shown on
your passport.
4
About the care you provide
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
Letters Numbers Letter
What relation is this person
to you?
If no relation, write None.
Their address
You do not have to live at
the same address as the
person you look after.
Postcode
Their daytime phone
number
Their date of birth
/ /
Day Month Year
No
Yes
Please give details on page 11.
We will also contact you about this.
Have you received any
payment from a local
authority, any other
organisation or individual
to care for the person you
are claiming Carer’s
Allowance for or anybody
else since your claim date?
For example – Payments for
Fostering, Adult Placements
or Direct Payments.
About the care you provide c
ontinued
No
Yes
Do you spend 35 hours or
more each week caring for
this person? A week is from
the start of a Sunday to the
end of the next Saturday.
No
Yes
Please give details on page 11.
We will also contact you about this.
Have you had any breaks in
looking after this person
since the date you want to
claim from?
For more information please read page 15 of the Notes.
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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
Please give details on page 11.
We will also contact you about this.
Have you had any breaks in
looking after this person in
the six months before the
date you want to claim from?
/ /
5
No
Yes
Does the person you look
after get Armed Forces
Independence Payment?
Statement on behalf of the person you look after
6
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 7.
Please ask them to read the notes below, then to
sign Statement 1 below. Then go to page 9.
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 7.
If you have ticked this box,
please tell us why on page 7.
Statement on behalf of the person you look after c
ontinued
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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.
No
Yes
Please go to Statement 3 on page 8.
Please read and sign the statement below. Then go
to page 9.
Do you act for the person
you look after?
Now return this form to your carer.
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.
Statement on behalf of the person you look after c
ontinued
8
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.
Full name
No
Yes
Please go to page 9.
Please ask them to read and sign the statement below.
Then go to page 9.
Does someone else act for
the person you look after?
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.
About your partner
No
Yes
Please go to page 10.
Please tell us about them below.
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'.
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
Their National Insurance
(NI) number
Letters Numbers Letter
Their date of birth
/ /
Day Month Year
9
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.
Please tell us about your partner, if you have one.
Other details
No
Yes
Please give details on page 11.
We will contact you about this.
Have you been on a course
of education since the date
you want to claim from?
No
Yes
Please give details on page 11.
We will contact you about this.
Have you been employed at
any time since six months
before the date you want to
claim from?
No
Yes
Please give details on page 11.
We will contact you about this.
Are you or have you been
self-employed since the
week before the date you
want to claim from?
It is important that you
read page 17 of the Notes
booklet for examples of
self-employment.
For more information please read pages 16 and 17 of the Notes.
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10
You Your partner
Have you or your partner
claimed or received any
other benefits since the
date you want to claim
from?
If you are waiting to hear
about a claim, still tick Yes.
Please include details for
your partner, even if you
have separated since the
date you want to claim from.
No
Yes
Please tell us the
names of the benefits
or entitlements
below.
No
Yes
Please tell us the
names of the benefits
or entitlements
below.
Other information
Please tell us anything else you think we should know about your claim.
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