Benefits Check Form

Section 1 - Your Contact Details





Please complete the details of EVERY person in your house including children in the form below.

When you are finished adding a person, press 'Submit'.

You will then be given the option to submit details of additional people.

Person 1.


Date of Birth


Please tick the box if this person recieves any of these benefits.

Care Component

DLA Low
DLA Middle/PIP Standard
DLA high/PIP enhanced

Mobility Component

DLA low/PIP standard
DLA higher/PIP enhanced
Motability Car

Attendance Allowance

Low
High

Please state how much of the following benefits this person receives.

Carers Allowance

Weekly Monthly

Housing / Council Tax Benefit

Weekly Monthly

Incapacity Benefit or JSA

Weekly Monthly

JSA

Weekly Monthly

Retirement Pension

Weekly Monthly

Industrial Injuries

Weekly Monthly

Income Support

Weekly Monthly

Pension Credit

Weekly Monthly

Other Benefits

Weekly Monthly

Wages

Weekly Monthly

Hours worked

Weekly Monthly

Any other pensions

Weekly Monthly

Working Tax Credits

Weekly Monthly

Child Tax Credit

Weekly Monthly

Other


Weekly Monthly

Savings, including ISAs, shares etc.

Details of illnesses or disabilities


How would you like to recieve your reply to this form application?

Email Letter No Preference