1S03 – OCT 2011
Q4 note: Please tick one box to
show the title you want to be
Who can get
Disability Allowance Application
If you, or a family member, have a disability, likely to continue for at least six months, you may
be able to get extra help through a Disability Allowance.
We may be able to help with costs such as ongoing visits to the doctor, medicines, medical
alarms and travel.
Your doctor or specialist will need to complete the Disability Certicate.
If you need help with this form call us on
0800 559 009.
Please read this
before you start
Please complete all questions – if not applicable write N/A.
1. What is your name?
Surname or family name
2. Are you known by or have you used any other names?
Please provide details below:
3. Are you: Male Female
4. What do you want to be called?
Mrs Miss Ms Mr No title Other
5. What is your date of birth?
Day Month Year
Q6 note: If you live in a rural area,
a house number could include:
RAPID number •
re number •
emergency services number. •
Q7 note: Mailing address includes:
postal box (PO Box) •
rural delivery details •
C/O address. •
6. Where do you live?
Flat/house no. Street name
7. What is your mailing address (if different from above)?
If you live at a rural address please include your rural delivery details here:
8. How can we contact you?
Work phone Home phone Mobile phone
Q2 note: Give any other names that
you use now or have used in the
past (including your maiden name).