Title, for example
Mr, Mrs, Miss, Ms
Surname or family name
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)
Letters Numbers Letter
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
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
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.