Fillable Printable Carer's Credit Application Form
Fillable Printable Carer's Credit Application Form
Carer's Credit Application Form
CC1 06/15
Carer’s Credit
Application form
● Use this form to apply for Carer’s Credit.
● You will already be getting credits if you get:
– Carer’s Allowance, or
– Child Benefit for a child under the age of 12.
So you don’t need to fill in this form.
● If you are a foster carer and will get National
Insurance Credits from HM Revenue & Customs,
you don’t need to fill in this form.
● Please read the Notes that came in the
application pack before you fill in this form.
● To find out if you might get Carer’s Credit,
answer the questions on page 3 of the Notes.
● The carer or their representative must fill in this
form, not the person being looked after.
● Please write clearly in ink.
● Please answer all the questions that apply to
you.
● If you want help filling in any part of this form,
or need an application pack in large print or
Braille, you can ring us on 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.
● If you live in Wales and would like us to contact
you in Welsh, please tick this box.
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.
Part 1: About you, the carer
Date of birth
/ /
Day Month Year
Postcode
Address
Please include your full
postcode. This will help us
deal with your application
more quickly.
If you have speech or hearing
difficulties and would like us
to contact you by textphone,
tick here.
Daytime phone number
where we can contact you or
leave a message. Please
include the area code.
Mobile number
Title, for example
Mr, Mrs, Miss, Ms
Surname or family name
Please answer the questions on this form in BLOCK CAPITALS.
All other names in full
All other surnames or family
names you have used or have
been known by
Please include
● the name you had before
getting married,
● all former married or
civil partnership names, and
● all changes of family name.
National Insurance number
You can get this from your
National Insurance number
card, letters about benefits,
payslips or form P60.
Letters Numbers Letter
2
Part 1: About you, the carer c
ontinued
For help with answering this question, please read the section
called When to apply on page 5 of the Notes.
When do you want your
Carer’s Credit to start?
/ /
Day Month Year
If you do not tell us a date, your
application may be delayed.
3
/ /
Day Month Year
From
When were you in prison or
legal custody?
/ /
Day Month Year
To
Have you been in prison or
legal custody since the
date you want your
Carer’s Credit to start from?
No
Yes
Do you normally live in
Great Britain?
By Great Britain we mean England,
Scotland and Wales.
Tick Yes if you are part of a family
living overseas with HM forces.
If you ticked No, where do you
normally live?
No
Yes
Part 2: About the care you provide
4
No
Yes
You will only be able to get Carer’s Credit
if you have looked after one or more
people for at least 20 hours a week.
Have you looked after one or
more people, for a total of
20 hours or more a week,
since the date you want to
apply from?
If you have looked after one or
more people for only some weeks
since this date, still tick Yes.
To find out more, see page 2 of
the Notes.
Their date of birth
Their address
You do not have to live at the
same address as the person you
look after.
Title,
For example Mr, Mrs, Miss, Ms
Their surname or family name
Their other names in full
/ /
Day Month Year
Person 1
Their National Insurance number
You can get this from their
National Insurance number card,
letters about benefits, payslips or
form P60. You can find the
National Insurance number for
children aged under 16 on letters
about Disability Living Allowance.
Please use this part to tell us about the people
you look after.
Postcode
Letters Numbers Letter
Part 2: About the care you provide c
ontinued
5
No
Yes
Does this person get
● Personal Independence
Payment at either rate of the
Daily Living Component, or
● Disability Living Allowance
care component at the middle
rate or the highest rate, or
● Attendance Allowance, or
● Constant Attendance
Allowance, or
● Armed Forces Independence
Payment?
You do not need to fill in a
Care Certificate for this person.
Ask a health or social care professional who knows
this person to fill in the Care Certificate that came in
this pack. Send the completed Care Certificate to us
with this application form.
If you need to send us a Care Certificate and you do not
send it with this form, your application may be delayed.
No
Yes
Have you had a break of
more than 12 weeks in
looking after this person,
since the date you want
your Carer’s Credit to start?
Please tell us about this below.
If you had any other breaks of more than 12 weeks,
please tell us about them at Part 3.
No
Yes
Do you look after more
than one person?
Please tell us about one other person on the next
page. If you need to tell us about more than two
people in total, please use the space at Part 3.
Please go to Part 3.
When did you start looking
after this person again?
/ /
Day Month Year
When did you stop looking
after this person?
/ /
Day Month Year
How many hours a week do
you look after this person?
h
ours a week
Please tick this box if the person
you look after gets Armed Forces
Independence Payment.
Part 2: About the care you provide c
ontinued
6
Their date of birth
Their address
You do not have to live at the
same address as the person you
look after.
Title,
For example Mr, Mrs, Miss, Ms
Their surname or family name
Their other names in full
/ /
Day Month Year
Person 2
Their National Insurance number
You can get this from their
National Insurance number card,
letters about benefits, payslips or
form P60. You can find the
National Insurance number for
children aged under 16 on letters
about Disability Living Allowance.
Postcode
Letters Numbers Letter
No
Yes
Does this person get
● Personal Independence
Payment at either rate of the
Daily Living Component, or
● Disability Living Allowance
care component at the middle
rate or the highest rate, or
● Attendance Allowance, or
● Constant Attendance
Allowance, or
● Armed Forces Independence
Payment?
You do not need to fill in a
Care Certificate for this person.
Ask a health or social care professional who knows
this person to fill in the Care Certificate that came in
this pack. Send the completed Care Certificate to us
with this application form.
How many hours a week do
you look after this person?
hours a week
If you need to send us a Care Certificate and you do not
send it with this form, your application may be delayed.
Please tick this box if the person
you look after gets Armed Forces
Independence Payment.
Part 2: About the care you provide c
ontinued
7
No
Yes
H
ave you had a break of
more than 12 weeks in
looking after this person,
since the date you want
your Carer’s Credit to start?
Please tell us about this below.
If you had any other breaks of more than 12 weeks,
please tell us about them at Part 3.
When did you start looking
after this person again?
/ /
Day Month Year
When did you stop looking
after this person?
/ /
Day Month Year
Part 3: Other information
Use this space to tell us anything
else you think we might need to
know. If there is not enough
space, please use a separate
sheet of paper.
Part 4: Declaration
8
I declare that the information I have given on this form is correct
and complete as far as I know and believe.
I understand that I must promptly tell you of anything that may
affect my entitlement to Carer’s Credit.
This is my application for Carer’s Credit.
Date
/ /
Signature
Part 5: What to do now
● Check that you have answered all the questions that apply to you.
● If we have asked you for a completed Care Certificate, ask a
health or social care professional to fill it in. Send the completed
Care Certificate to us with this form.
● Check that you have signed at Part 4.
● Send everything to us in the envelope that came with this
application pack. The envelope does not need a stamp.
● Our address is
Carers Allowance Unit
Mail Handling Site A
Wolverhampton
WV98 2AB.
CC1_062015_005_001
