DS700 Carer Alllowance Claim Form

Carers Allowance
Claim form
Department for
Communities
Use
this form to claim Carers

Allowance.
Please
Please
Please
You,
Contact
read the Notes that came

with the claim pack before you fill in
the form.
the carer, should fill in this
form, and not the person you look
after. Someone else can fill in the
form for you, but you must sign the
form yourself.
fill in this form in BLACK INK

and in CAPITALS.
answer all the questions
and send us all the documents we
ask for.
us if you cannot fill in this
form or send us the documents
we ask for. This might delay your
claim.
The quickest and easiest way to claim Carers Allowance is online.

Check if you can get Carers Allowance and make a claim at
www.nidirect.gov.uk/services/apply-carers-allowance
This form and notes are available in large print or braille.

Please call us on 0300 123 3356.
If you have speech or hearing difficulties, you can
contact us by textphone on 028 9031 1092. Our
textphone service does not receive messages from
mobile phones.
Calls to 03 numbers cost no more than a national
rate call to an 01 or 02 number. They must also count
towards any inclusive minutes in a phone contract in
the same way as 01 and 02 calls.
These rules apply to calls from any type of line including
mobile, landline or payphone.
DS700
Version 01/16
About your Carers Allowance

When do you want your
Carers 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
/
Please make a note of this

date as we will ask you
about it again later.
Example of an exact date

11
01
/ 2016
For more information please read page 6 of the Notes.
About you the carer

Title, for example
Mr, Mrs, Miss, Ms.
Surname or family name
All other names in full
All other surnames or family
names you have used or have
been known by
Your National Insurance
(NI) number
Letters Numbers
Letter
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.
Your Date of birth
Day
/
Your Address
Month Year
Postcode
About you the carer continued
Daytime phone number

where we can contact you
or leave a message. Please
include the dialling code.
If you have speech or hearing difficulties and would like

us to contact you by textphone, tick here.
Mobile number
What is your nationality?
For example, British or Irish.
If you have a current
passport, please give your
nationality as shown on
the passport.
Have you always lived
in Northern Ireland?
No
Go to the next question.
Yes
Go to About your partner.
Are you currently living

No
We will contact you about this.
Yes
Go to the next question.
When did you arrive

What country did you

come from?
Do you plan to go back to
that country?
No
Yes
Please tell us when.
What is the visa reference

number in your passport?
This is normally two letters
followed by six numbers, for
example AB123456. It is not
your passport number.
If there are other personal details you think we should
know, for example previous names or addresses, please tell
us about them on page 24.
About your partner

Please tell us about your partner, if you have one.
By partner we mean:
a person you are married to or live with as if you are
married, or
a civil partner or a person you live with as if you are civil
partners.
What is your marital or
civil partnership status?
single
separated
married or civil partner
divorced or civil
partnership dissolved
widowed or surviving
civil partner
living with partner

Have you lived with a
partner 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 from,
we still need to know their
details.
No
Please go to page 6.
Yes
If your partner joined your household after

the date you want to claim from, tell us the
date they joined.
Have you separated from

your partner since the date
you want to claim from?
No
Yes
When did you separate?

/
Your partners 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
About your partner continued

Their National Insurance
(NI) number
Letters Numbers
Letter
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.
Day
Their date of birth
Month Year
/
Their address
if different from yours
Postcode
What is their nationality?

For example, British or Irish.
About the care you provide

Please tell us about the person you look after.
This will help us deal with your claim more quickly.
Their Title, for example
Mr, Mrs, Miss, Ms.
Their surname or family
name
(NI) number
Letters Numbers
Letter
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 childs NI
number is the reference number on letters about Disability
Living Allowance for the child.
This will help us deal with your claim more quickly.
Their date of birth
Day

Month Year
/
Their address
You do not have to live at
the same address as the
person you look after.
Postcode
Their daytime phone
number, including dialling
code. We will not give this
number to anyone else.
What relation is this person
to you?
If no relation, write None.
Does the person you look after get

Armed Forces Independence Payment?
No
Have you received any payment from an

individual, a Health and Social Care Trust
or government department or any other
organisation to look after this person
since this date you want to claim from?
For example - payments for fostering or
Adult Placement.
No
Yes
Yes
Please give details on page 24.

We will also contact you about this.
About the care you provide continued

name
Their address
Postcode
How much do they pay
you each week?
When did you start getting

this money?
Has anyone else claimed
Carers Allowance for this
person before?
Two people cannot get
Carers Allowance at the
same time for looking after
the same person.
No
Yes
Please tell us about the person who claimed below.
For more information please read page 4 of the Notes.

name
Their address
Postcode
(NI) number, if you know it.
Their date of birth
Letters Numbers
Letter

Do you spend 35 hours or
more each week caring for
the person you look after?
No
Have you had any breaks

in looking after this person
since the date you want to
claim from?
No
Yes
Yes
Use the table below to give us the exact

dates and times of the breaks.
A break is any time when you spent less than

35 hours a week looking after the person. For
example, when
they were in respite care, hospital or on
holiday without you
you were in hospital, care facility or on
holiday without them.
Please put a tick in one 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.
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:
observation
therapy
support services
advice and training in social and domestic skills.
It does not include straightforward care or attention by unqualified staff.

Date
Time
Reason for the break
From
am/pm
To
am/pm
From
am/pm
To
am/pm
From
am/pm
To
am/pm
You were
getting
treatment
If you had more than three breaks, please tell us about them on page 24.
The person you look

after was getting
treatment

Did you look after this
person for at least 35
hours each week before
claim from?
No
Have you had any other

breaks in looking after this
person in the 6 months
before the date you want
to claim from?
No
Date
Yes
When did you start to look after this person?

/
Yes
Time
Use the table below to give us the exact

dates and times of the breaks.
Reason for the break
From
am/pm
To
am/pm
From
am/pm
To
am/pm
From
am/pm
To
am/pm
You were The person you look

getting
after was getting
treatment treatment
If you had more than three breaks, please tell us about them on page 24.
Please put a tick in one 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.
Was the person you look
after away from home in
any of the breaks you have
told us about?
No
Yes
Where did they stay?
Postcode
Statement on behalf of the person you look after

The person you look after needs to know if you are claiming
Carers 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.
If the person you look after is unable to sign
Can the person you look
No
Statement 1 because of a health condition, a
after sign a statement?
disability, or because they are under 16, someone
who acts for them can sign on their behalf. Please
go to Statement 2 on page 11
Yes
Please ask them to read the notes below, then to

sign Statement 1 below. Then go to page 13.
Notes for the person being looked after

If you get a severe disability premium with your
Income-based Jobseekers Allowance, Income Support,
Income-related Employment and Support Allowance, or
Housing Benefit, you may no longer get that premium if
we pay Carers Allowance to your carer.
This may also reflect any Rates Relief you are entitled to.
If your Pension Credit includes an extra amount for
severe disability, you may no longer get that extra
amount if we pay Carers Allowance to your carer.
For more information about this, contact the office that
deals with your benefit or entitlement.
If we pay Carers 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.
Statement 1
I understand that the carer named on page 1 is making a claim for
Carers 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 Carers Allowance.
Please tick one of the following boxes.
I can confirm that the carer named on page 2
looks after me for at least 35 hours a week.
I cannot confirm that the carer named on page 2
looks after me for at least 35 hours a week.
10
If you have ticked this box,

please tell us why on page 11.
Statement 1 continues on page 11.
Statement on behalf of the person you look after continued

Signature
Date
If you cannot confirm that

the carer named on page2
looks after you for at least
35 hours a week, please tell
us why.
Now return this form to your carer.
Statement 2
Do you act for the person
you look after?
No
Please go to Statement 3 on page 12
Yes
Please read and sign the statement below. Then go

to page 13.

I am acting for benefit purposes for the person being looked
after, and I am their
parent or guardian
attorney
appointee
controller
I understand that my claim for Carers Allowance
may affect some of their benefits (see page 12 of the Notes booklet
for further information about how the disabled persons benefits
may be affected).
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 Carers Allowance
Signature
Date
11
Statement on behalf of the person you look after continued

Statement 3
Does someone else
act for the person
you look after?
No
Yes
Please ask them to read and sign the statement

below. Then go to page 13.

I am acting for benefit purposes for the person
being looked after, and I am their
parent or guardian
attorney
appointee
controller
I understand that this claim for Carers Allowance may affect some of their benefits
(see page 12 of the Notes booklet for further information about how the disabled
persons benefits may be affected).
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 Carers Allowance.
I can confirm that the carer named on page 2
looks after the person being cared for,
for at least 35 hours a week.
I cannot confirm that the carer named on page 2
looks after the person being cared for,
for at least 35 hours a week.
Signature
Full name
Date
If you cannot confirm
that the carer named on
page2 looks after the
person being cared for, for
at least 35 hours a week,
please tell us why.
12
About time spent abroad

Do you normally live in
Northern Ireland?
No
Yes
If No, where do you

normally live?
If you normally live outside
Northern Ireland but in the
European Economic Area
(EEA) or in Switzerland, we
may need to ask for more
information.
Are you in Northern Ireland
now?
No
Have you been out of

Northern Ireland with
the person you look after
for more than four weeks
claim from?
No
Where did you go?
Yes
Yes
We may contact you about this.
Why did you go?
Have you been away from

No
Northern Ireland for more
Yes
than 52 weeks in the last
3 years?
This doesnt have to be 52
weeks in a single period. Add
up all the times youve been
away in the last 3 years, and
if it comes to more than 52
weeks, tick Yes.
Where did you go?
Date you left

Northern Ireland
Date you returned

to Northern Ireland
Please tell us about this below.
Why did you go?
Date you left

Northern Ireland
Date you returned

to Northern Ireland
13
About education
Have you been on a course
of education since the date
If you are on holiday or on
temporary leave from your
course, still tick Yes.
No
Yes
Type of course
For example, A-level, degree,
diploma, correspondence
course, Open University.
Course title
Name of school, college
oruniversity
Address
Postcode
Phone number
including the dialling code
Fax number (if you know it)
Your student reference
number
Name of main teacher
or tutor
14
When did you start your

course?
When do you expect the

course to end?
If you are no longer on the

course, when did you finish?
About employment
By employment we mean:
full-time or part-time work
work on a zero hours contract
casual or temporary work
job sharing
being included in a tax return as a worker
being a company director
being in the Army Reserve or other auxiliary armed forces, or
being on a career break or taking unpaid leave.
Have you been employed
at any time since 6months
to claim from?
This is the date you put on
page 2 of this form. Still
tick Yes if you are off work
because you are sick, on
parental leave or on
unpaid leave.
No
Yes
Please tell us about your main job below. If

you have more than one job, please tell us
about this on page 24.
When did you start

this job?
Has the job finished?
/
No
Yes
When did you

last work?
What is the
leaving date on
your P45, if you
have one?
Type of job
Clock or payroll number
Employers name
Employers address
Postcode
Employers phone number
Employers fax number
15
About employment continued

Which department deals
with your wages?
For example, Personnel,
Wages, Human Resources.
Please give us a contact
phone number for this
department.
How many hours a week
do you or did you
normally work?
When were you
last paid?
From
What period did this cover?
What was your gross pay?
By gross pay we mean the
amount before anything is
taken off.
What was included in this
pay?
Include things like holiday
pay, redundancy or a
payment instead of notice
(PILON). Give us full details
of everything paid to you
and what period each
payment was for.
How often are you or were
you paid?
To
/
weekly
fortnightly
four-weekly
monthly
other
When do you or did you

get paid?
For example, every Friday,
the last day of every month,
every fourth Friday, 15th of
every month.
16
Do you or did you get

paid the same amount
each time?
No
Yes
Please say how often.

Do you or did you get
holiday pay or sick pay?
No
Do you or did you get paid

any other money as well as
your normal wage?
For example, tips.
No
Does your employer owe

you any money?
Include things like holiday
pay, redundancy or a
payment instead of notice
(PILON).
No
Have you worked for any

other employer in the
6months before the date
No
Yes
Yes
Yes
Yes
Please tell us what else you get or got.
Please give us the name and address of your

other employer. If you have more than one other
employer, please tell us about them on page 24,
including the start and end dates of each
employment.
Employers name
Employers address
Postcode
Employers phone number
Employers fax number
Has the job finished?
No
Yes
If yes:
When did you
last work?
What is the
leaving date on
your P45, if you
have one?
17

Evidence of earnings
Now send us:

your P-45, if you have one,

the last payslip you got before the date
you want to claim from, and
any payslips you have had since then.
About expenses to do with your employment

Do you or did you pay
towards an occupational
pension scheme?
No

towards a personal or
stakeholder pension
scheme or a retirement
annuity scheme?
No
Do you or did you pay for

anything necessary to do
your job?
For example, tools or
protective clothing.
No
Yes
How much do you or did you pay, and how often?

Yes
every

every
Please send us written proof of this amount.

Yes
What are or were these

things?
Why do you or did you need

these things to do your job?
How much do or did these

things cost you each week?
While at work, do you or
did you pay for childcare?
18
a week
No
Yes
How much?

a week
About expenses to do with your employment continued

What relation, if any, is
the person to you, to your
partner and to the person
you look after?
For example uncle,
sister, brother-in-law,
grandmother, none.
Relationship to you
Relationship
to your partner
Relationship to
the person you look
after
Their name
Their address
What is your or your

partners Child Benefit
number?
You can find this on letters
about Child Benefit.
Numbers

did you pay anyone to look
after the person you care
for?
No
Letters
CHB
Yes
How much?

a week
What relation, if any, is

this person to you and
to your partner?
Their name
Their address
Postcode
What relation, if any, is this
person to the person you
normally look after?
19
About property you rent out

Do you or your partner own
property or land in the UK
or abroad, that you have
rented out since the week
to claim from?
No
Have you sublet your home,

or provided board and
lodgings, since the week
to claim from?
No
Yes
Yes
About self-employment
Self-employment could mean:
working for yourself, or
being a partner or sleeping partner in a business.
Have you paid Class 2
(self-employed) National
Insurance contributions
since the week before the
date you want to claim
from?
No
Yes
Have you been selfemployed at any time

since the week before
claim from?
No
Yes
Please tell us about this below
Are you self-employed

now?
Have you ceased trading?
20
When did you start this work?
When did the work finish,

if it has?
No
Tell us on page 21 about your most recent

self-employed work.
Yes
Tell us on page 21 about your current

self-employed work.
No
Please go to page 21
Yes
If you ceased trading more than a week before the

date you want to claim from, please go to page 22.
About self-employment continued

What type of work or
business is it?
What is or was your trading
year?
From
To
/
Please send the most recent finalised accounts you have for
your business, with this form.
Are these accounts

prepared on a cash
flow basis?
No
Are the income, outgoings

and profit in these
accounts similar to your
current level of trading?
No
Have you got an

accountant?
No
Can we contact your

accountant if we need to?
No
Yes
Yes
Yes
Please tell us about them below.
Yes
Accountants name
Accountants address
Postcode
Accountants phone number
Accountants fax number,
if you know it
towards a personal or
stakeholder pension
scheme or a retirement
annuity scheme?
No

did you pay for childcare
or for someone to look
after the person you care
for?
No
Yes

every
Yes
21
About other money

You
Have you or your partner
claimed or received any
other benefits since the
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
from.
No
Has anyone had any money

added to a benefit for you
claim from?
No
Yes
Yes
Your partner
No
Yes
Please tell us the
names of the benefits
or entitlements below.
Please tell us the

names of the benefits
or entitlements below.
Please tell us about the person who gets extra

money for you.
For example, this could be extra money

that your partner gets for you with their
Employment and Support Allowance or
State Pension.
If you are under 19 years of age,
include any payment your parent or
guardian gets for you, which is added to
any other benefit or entitlement.
Their name
Their address
Postcode
(NI) number, if you know it
Name of the benefit
22
Letters Numbers
Letter
About other money continued

Have you had any Statutory
Sick Pay (SSP), Statutory
Maternity Pay (SMP),
Statutory Paternity Pay
(SPP) or Statutory Adoption
Pay (SAP) since the date
If you are waiting to hear
about SMP, SPP or SAP,
still tick Yes.
No
Yes
Please tell us about the employer who deals with

your SMP, SPP or SAP.
Employers name
Employers address
Postcode
How much do you or did you
get, and how often?
every

Do you, or any member of
your family receive any
benefits or pensions from
another EEA State
or Switzerland?
No
Have you, or any member

of your family made a
claim for any benefits or
pensions which has not
yet been decided from
another EEA State
or Switzerland?
No
Are you, or any member

of your family, working
in or paying insurance
to another EEA State or
Switzerland?
No
Yes
Yes
Yes
If yes please give details on page 24. We will contact

you if we need any additional information.


23
About your illnesses or disabilities and the

Other
information
treatment
or help you receive
Please tell us anything else you think we should know about your claim.
2424
24
How we pay you

We can pay your Carers Allowance every 13 weeks, every
fourweeks or every week. It will normally be paid on a Monday.
How often do you want
us to pay your benefit?
Please tick one box.
Every week
in advance
Every four weeks
three weeks in arrears and

one week in advance
in arrears
Every 13 weeks
We normally pay your money into an account.

Many banks and building societies will let you collect your money
at the post office.
We will tell you when we will make the first payment and how
much it will be for. We will tell you if the amount we pay into the
account is going to change.
Finding out how much we have paid into the account
You can check your payments on account statements. The
statements may show your National Insurance (NI) number next to
any payments we have made. If you think a payment is wrong, get
in touch with the office that pays you straightaway.
If we pay you too much money
We have the right to take back any money we pay that you are not
entitled to. This may be because of the way the system works for
payments into an account.
For example, you may give us some information, which means
you are entitled to less money. Sometimes we may not be able to
change the amount we have already paid you. This means we will
have paid you money that you are not entitledto.
We will contact you before we take back any money.
What to do now
Tell
us about the account you want to use on the next page. By

giving us your account details you:
agree that we will pay you into an account, and
understand what we have told you above in the section If we
pay you toomuch money.
If
you are going to open an account, please tell us your account

details as soon as you get them.
If
you do not have an account, please contact us and we will give

you moreinformation.
Fill in the rest of this form. You do not have to wait until you
have opened an account or contacted us.
25
25
How we pay you continued

About the account you want to use
can use an account in your name, or a joint account.
You can use someone elses account if:
the terms and conditions of their account allow this, and
they agree to let you use their account, and
you are sure they will use your money in the way you tell them.
You can use a credit union account. You must tell us the credit unions
account details. Your credit union will be able to help you with this.
If you are an appointee or a legal representative acting on behalf of the
customer, the account should be in your name only.
You
Please tell us your account details below.

It is very important you fill in all the boxes correctly, including the building
society roll or reference number, if you have one. If you tell us the wrong
account details your payment may be delayed or you may lose money.
You can find the account details on your chequebook or bank statements. Ifyou
do not know the account details, ask the bank or building society.
Name of the account holder
Please write the name of the
account holder exactly as it is
shown on the chequebook or
statement.
ull name of bank or
F
building society
Sort code
Please tell us all six numbers,
for example 123456
Account number
Most account numbers are
eightnumbers long.
If your account number has fewer than 10 numbers, please
fill in the numbers from the left.
uilding society roll or reference number
B
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.
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 this box.
26
Consent
We may wish to contact your current or previous employers,
or other people or organisations you have told us about on
this form, for information about your claim. You do not have
to agree to us contacting these people or organisations. But
if you do not agree to this, it may mean that we cannot get
enough information to be sure that you meet the conditions
of entitlement for your claim.
Do you agree to us getting information from any current or
previous employer you have told us about on this form?
No
Yes
Do you agree to us getting information from any other person No

or organisation you have told us about on this form?
Yes
If you have answered No to either statement, please tell us
why on page 24.
Declaration
If you do not sign your declaration, we cannot accept this
form and we will return it to you.
I declare that the information Ihave given on this form is
correct and complete as far as I know and believe.
I understand that if I knowingly give information that is
incorrect or incomplete, my benefit may be stopped and Imay
be liable to prosecution or other action.
I understand the information I have provided will be used to
process my application for Carers Allowance and may be used
to decide my entitlement to other benefits.
I understand that Imust promptly tell the office that pays my
Carers Allowance of anything that may affect my entitlement
to, or the amount of, that benefit.
This is my claim for Carers Allowance.
Signature
Date
Now please read What to do now on the next page.
27
What to do now
Check
that you have answered all of the questions.

Check that you are sending us all the documents we have asked for. These could be things like:
payslips
copies of accounts and balance sheets
P45
Contact us if you cannot fill in the form or send us the documents we ask for. Any benefit you may
be entitled to may be delayed.
Check that you have signed the form on page 27.
Check that the person you look after, or someone who acts on their behalf, has read the notes
on page 12 and has filled in and signed one of the statements.
Send everything to us in the envelope that came with this claim pack. The envelope does not
need a stamp.
Our address is: Disability and Carers Service, Castle Court, 12-56 Royal Avenue, Belfast, BT1 1HR
Department for Communities Privacy Notice

How we collect and use information about you
The Department for Communities (DfC) takes care to ensure that any personal information supplied to it complies
with the requirements of the Data Protection Act 1998. When we collect information about you we may use it for
any of our purposes including:
Supporting you in your search for future employment;
Administration of benefits;
Occupational health and welfare;
Prevention and detection of fraud or maladministration;
Compilation of statistics; and
Disclosure to other organisations when legislatively required to do so.
We may also check information we collect about you with other information we hold as well as information provided
by other organisations. We may also get information about you from other organisations for any of our purposes if
the law allows us to do so.
We may share your personal information with other organisations to protect public funds; detect and prevent fraud;
and to check its accuracy. Data will only be shared where the law allows us to and where data sharing agreements
exist. Organisations that we may share your data with include:
Other NI and UK government departments;
Councils and other public sector organisations:
Private-sector organisations such as banks and third party private-sector debt collection agencies; and
Employers via Direct Earnings Attachments.
You have a right under the Data Protection Act 1998 to see a copy of the information we hold about you.
To find out more about how we use information, visit our website www.communities-ni.gov.uk/publications/dfcinformation-charter or contact any of our offices.
28
Produced for DfC by CDS 161648 09/16

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Carers Allowance

this form to claim Carers

read the Notes that came

fill in this form in BLACK INK

The quickest and easiest way to claim Carers Allowance is online.

This form and notes are available in large print or braille.

About your Carers Allowance

Please make a note of this

Example of an exact date

For more information please read page 6 of the Notes.

About you the carer

About you the carer continued

Daytime phone number

If you have speech or hearing difficulties and would like

Go to the next question.

Go to About your partner.

Are you currently living

We will contact you about this.

Go to the next question.

When did you arrive

What country did you

Please tell us when.

What is the visa reference

About your partner

married or civil partner

living with partner

If your partner joined your household after

Have you separated from

When did you separate?

Your partners title, for

Their other names in full

All other surnames or family

About your partner continued

What is their nationality?

About the care you provide

Does the person you look after get

Have you received any payment from an

Please give details on page 24.

About the care you provide continued

When did you start getting

Please tell us about the person who claimed below.

For more information please read page 4 of the Notes.

Their surname or family

About the care you provide continued

Have you had any breaks

Use the table below to give us the exact

A break is any time when you spent less than

It does not include straightforward care or attention by unqualified staff.

Reason for the break

The person you look

About the care you provide continued

Have you had any other

When did you start to look after this person?

Use the table below to give us the exact

Reason for the break

You were The person you look

Where did they stay?

Statement on behalf of the person you look after

Please ask them to read the notes below, then to