Child Benefit Claim Form

Page 4
For office use onl y - not for completion by DO – birth certificates extraction
Signature 1 Name in capitals Signature 2 Name in capitals Date
Child 1
Child 2
Child 3
Child 4
F
or office
use 6
F
or office
u
se 5
3rd CHILD
S
urname
O
ther name(s)
S
ex
Date of birth
M
ale Female
D D M M Y Y
4th CHILD
S
urname
O
ther name(s)
Sex
Date of birth
Male Female
D D M M Y Y
We need to see the original
birth certificate, or
adoption certificate
for each child in this claim.
Do not send photocopies.
If you have, or someone else has , received
Child Benefit for the child in the past, do not
send us the birth certificate.
Please tell us ho w many certificates you are sending with this form.
If you cannot send any certificates with the form ple ase tell us why
in Part 6
How many birth certificates
How many adoption certificates
P ART 3 CHILDREN YOU W AN T TO CLAIM FOR continued
F
or Chil
d Benefit Office use only - not f or completion by DWP office or HMRC Enquiry Centre
– bir
th c
ertificates extraction
Has anyone else ever claimed Child Benefit
for any of the children you w ant to claim for?
See not
es
, page 12
No
Y es If yes, plea se tell us about the person who made the claim
The full name o f the person who claimed (if you know it)
The address the claim was made from (if you know it)
The Child Benefit number (if you know it)
C H B
P
os
tcode
Please tell us about the childr en you want to claim for now . Do not tell us about any children you already get
Child Benefit for.
Please enter the name exactly as shown on the child’ s birth or adoption certificate.
If you want to claim for more than 4 childr en, use the space in P art 6 to tell us about them.
Page 4/12
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Child Benefit Claim Form PDF

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