Carers Allowance Form Sample

3861BE0A
Your own details (carers Details)
Part 1 continued
Your work and claim detailsPart 2
Type of work:
13.If you are married, in a civil partnership or cohabiting, from what date?
D D MM Y Y Y Y
12.Are you?
Single
Married
Separated
Divorced
Widowed
Cohabiting
In a Civil Partnership
A surviving Civil Partner
A former Civil Partner
(you were in a Civil Partnership
that has since been dissolved)
Employer’s name:
Employer’s address:
15(a). Are you employed at present?
Yes
No
If ‘Yes’, please state:
Gross weekly
earnings:
Please attach 3 of your most recent payslips.
a week
, .
Carer’s Allowance is a means tested payment. You are legally obliged to declare all your
means which include money in cash or in a financial institution, savings, shares, bonds,
funds, property (other than your own home), foreign pensions etc. Please include written
evidence such as statements and payslips with your application. Failure to do so could
result in a delay in processing your application.
You must also declare the means of your spouse, civil partner or cohabitant.
15(b).
You can work for up to 15 hours a week outside the home. Do you intend to....?
or
(a) remain at work for up to 15 hours a week:
(b) return to work for up to 15 hours a week:
Yes
No
Yes No
Page 2
14.If you previously lived or worked in the UK, please state your UK Social Security Number:
CF3CC584
Page 4/32
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Carers Allowance Form Sample PDF

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