your claim for incapacity beneﬁt - the national...

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Your claim forIncapacity Benefit

You should use this form to claim Incapacity Benefit.

For more information on who should claim, please read the notes thatcome with this pack. You should read these notes before you fill in thisform.

There are 3 sections in this form. Everyone should fill in sections 1 and 3.You only need to fill in section 2 if you want to claim extra IncapacityBenefit for another adult.

If you need help to fill in this formIf you need help to fill in this form, you can ask someone else to fill it infor you, or you can contact your social security office.

If you are filling this form in for someone else, we will ask you for yourname and address in Section 3, Part 19. Please remember to fill in the restof the form with their details, not yours.

Benefit you may get because of this claim will be paid more quickly if you● answer all the questions on this form that apply to you, and your partner

if you have one, and● you send us all the documents we ask for.

If you cannot do this, get in touch with us straight away. If you do not, youmay lose benefit.

We use partner to mean a person you are married to or a person you areliving with as if you are married to them.

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What is Incapacity Benefit?

Claim pack for Incapacity Benefit

Incapacity Benefit is a social security benefit for people who have anillness or disability. Sick or sickness is now referred to as illness ordisability.

You may be able to get Incapacity Benefit if you have an illness ordisability and● you are unemployed, or● you are self-employed, or● you work for an employer but you cannot get Statutory Sick Pay (SSP).

Statutory Sick Pay (SSP) is money paid by employers to employees whoare away from work for 4 days or more in a row because of their illnessor disability.

People who have special medical treatment may get Incapacity Benefitinstead of SSP even if they work for an employer.

By special medical treatment we mean● dialysis● radiotherapy● chemotherapy● plasmapheresis● total parenteral nutrition for gross impairment of enteric function.

You can find out more about Incapacity Benefit in leaflets IB1 A guide toIncapacity Benefit or SD1 Sick or disabled. You can get these leaflets fromany Jobcentre Plus or social security office.

Who you can claim extra Incapacity Benefit forClaiming extra Incapacity Benefit for an adultIf you have any children living with youYou may be able to get extra Incapacity Benefit for● your husband or wife, or● someone who looks after children for you.

If you are claiming for a partnerFrom April 2004 there is a change in the rules if you are claiming anincrease of Incapacity Benefit for your partner.By partner we mean someone you are married to and living with or aperson you live with as if you are married to them.

We may need your partner to go to a work focused interview with apersonal adviser.

Your partner will not have to go to a work focused interview unlessyou have been claiming Incapacity Benefit for 26 weeks or more. Wewill let them know if they have to go.

If your partner does not take part in the work focused interviewwithout good reason your benefit may be affected.

If you do not have any childrenYou may be able to get extra Incapacity Benefit for your husband orwife if they are aged 60 or over. They will not need to go to a workfocused interview.

Not

es

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When to claim

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If you are● unemployed, or● self-employed, or● you work for an employer but you cannot get Statutory Sick Pay (SSP)fill in claim form SC1 as soon as you can after you have been unable towork for 4 days or more in a row because of your illness or disability.

Do not delay sending in your claim form. If you wait, you could losemoney.

Please note that we cannot pay your benefit for a period more than3 months before the date we receive your claim.

You do not need a medical certificate from your doctor for the first weekthat you are unable to work. But if you need medical advice or treatment,go to your doctor straight away.

If you are claiming Incapacity Benefit and have had one or more shortspells of incapacity totalling more than 7 days within the last 8 weeks, youwill need to get a medical certificate from your doctor for this claim. Medical certificates are also called sick notes, doctor’s notes or doctor’sstatements.

If you are still unable to work after 7 days, you will need to see yourdoctor and send any medical certificate you are given to your JobcentrePlus or social security office.

If you have special medical treatment, fill in claim form SC1 as soon asyour treatment means that you cannot work for 2 days or more.These days do not have to be in a row, but they must be within a 7 dayperiod starting with any day of the week.

Child Tax CreditFrom 6 April 2003 you cannot claim an increase for children but you canclaim Child Tax Credit instead. To find out more about Child Tax Creditvisit www.inlandrevenue.gov.uk/taxcreditsYou can claim online too.

You can also phone the Inland Revenue by calling the Helpline on thefollowing numbers:England, Scotland and Wales – 0845 300 3900Northern Ireland only – 0845 603 2000

Textphone for people with hearing or speech difficulties:England, Scotland and Wales – 0845 300 3909Northern Ireland only – 0845 607 6078

Lines open 8am–8pm seven days a week (except Christmas Day, BoxingDay, New Year’s Day and Easter Sunday).

If you need help or a form in Welsh, please phone 0845 302 1489. Linesare open 8.30am–5pm Monday to Friday.

Who you can claim extra Incapacity Benefit for – continued

Please fill in claim form SC1 that comes with this pack. Please use a pen only when completing the form.

Make sure you read the rest of these notes. They will help you tomake your claim.

How to claim

Disability Living AllowanceThis is a social security benefit for people with an illness or disabilitywho need● help with getting around, or● help with personal care, or● help with both of these.

If you want to find out more about this, get leaflet DS704 DisabilityLiving Allowance – you could benefit from any Jobcentre Plus or socialsecurity office.

Incapacity Benefit for young peopleIncapacity Benefit is available for young people aged 16 or over butunder 20 (or aged 20 or over but under 25 in some cases) who

● have been incapacitated early in life

● are unable to work because of illness or disability

● have not paid enough National Insurance (NI) contributions to be ableto get Incapacity Benefit under the normal rules.

For more detailed information about Incapacity Benefit, get leaflet IB1A guide to Incapacity Benefit from your Jobcentre Plus or social securityoffice.

Other help

3

If you work for an employer or you worked for an employer on thedate you are claiming Incapacity Benefit from, you may be able to getStatutory Sick Pay (SSP) instead.

SSP is money paid by employers to employees who are away from workfor 4 days or more in a row because of their illness or disability.

If you want more information about SSP, get in touch with youremployer.

Statutory Sick Pay (SSP)

If you have special medical treatment every week, fill in claim formSC1 for the first week that you have your treatment.Please get a medical certificate or letter from your doctor or hospital.This should say● what treatment you are getting● which days of the week you cannot work● how long your treatment will last.

Send the medical certificate or letter to your Jobcentre Plus or socialsecurity office as soon as you can. But do not delay sending in yourclaim form.

You can find the address of your Jobcentre Plus or social security officeon the advert in the business numbers section of the phone book. Lookunder Social Security. You can get an envelope from any post office. Itwill not need a stamp.

If you have special medical treatment occasionally, fill in claim formSC1 each time that your treatment means that you cannot work for2 days or more.

When to claim – continued

Other help – continued

Industrial Injuries Disablement BenefitThis is a social security benefit for people who are disabled because of● an accident at work, or● an industrial disease.If you want to find out more about this, get leaflet SD7 Disabled because ofan accident at work? or leaflet SD6 ill or disabled because of a disease ordeafness caused by work? from your Jobcentre Plus or social security office.

Working Tax CreditThis is a tax credit to top up the earnings of working people. You can claimWorking Tax Credit if● you are aged 16 or over, and● you work at least 16 hours a week, and● you or your partner are responsible for a child or young person, or● you have a disability which puts you at a disadvantage in getting a job, or● you or your partner are aged 50 or more and are returning to work after a

spell on qualifying out of work benefits.

If you do not have children or a disability that puts you at a disadvantage ingetting a job, you can also claim Working Tax Credit if● you are aged 25 or over, and● you work at least 30 hours a week.

The Working Tax Credit is available to self-employed people and employees.If you want to know more about Working Tax Credit contact the InlandRevenue on the numbers listed on page 1 of these Notes.

Income SupportYou may be able to get Income Support if you cannot get Incapacity Benefit,or if your Incapacity Benefit does not give you enough money to live on. Ifyou think you may be able to get Income Support, you should claim straightaway because Income Support will only be payable from the date yourIncome Support claim is received by your Jobcentre Plus or social securityoffice. Ask for leaflet SD2 Sick and unable to work? from your Jobcentre Plusor social security office.

Pension CreditYou may be entitled to Pension Credit if you are aged 60 or over. You canapply for Pension Credit by phoning The Pension Service on 0800 99 1234.For people with speech or hearing difficulties using a textphone the numberis 0800 16 90 133. Lines are open 8.00am to 8.00pm Monday to Friday and9.00am to 1.00pm on Saturday.

You may also apply on the internet. Visit the website atwww.thepensionservice.gov.uk/pension.credit

For general information about Pension Credit see leaflet PC1L Pension Credit– Pick it up. It’s yours. You can get it from your Jobcentre Plus, social securityoffice or Pension Centre.

Jobseeker’s AllowanceThis is a social security benefit for people who are unemployed and lookingfor work.

NHS chargesYou may be able to get help with paying for things like NHS prescriptionsand NHS dental treatment.

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If you are entitled to Incapacity Benefit for less than a whole week, theamount that you get for each day will be the weekly amount divided by 7.

When we work out your Incapacity Benefit we round the amounts to thenearest penny.

You will not normally get any Incapacity Benefit for the first 3 days that youcannot work because of your illness or disability. We call these waiting days.

You may get Incapacity Benefit for these 3 days if● you have been getting Incapacity Benefit or Statutory Sick Pay (SSP) within

8 weeks of your present claim, or● you have been getting Incapacity Benefit and you are entitled to the

52 week benefit protection, or● you have attended a recognised training course and it is 2 years or less since

you last claimed Incapacity Benefit.

You may also get Incapacity Benefit for these 3 days if you have been getting● Disabled Person’s Tax Credit, or ● a disability element of Working Tax Credit, whether or not it is paid, or● you are paid Working Tax Credit or Child Tax Credit at a higher rate

than the family element, and

● it is 2 years or less since you last claimed Incapacity Benefit.

How your money is worked out

5

Making payments to you

Our policy is to pay all benefits directly into an account. This is the safest wayto pay you and lets you choose how and when you get your money. You canuse a bank or building society account. You may be able to use a cashmachine, which will usually mean you can get your money at any time of theday or night. The Post Office® also provides a bank account that we can paybenefits into. With this account you can only collect your money in cash fromPost Office branches. There are arrangements with a number of major banksand building societies so that you can collect cash from some of theiraccounts at your local Post Office. Section 3 Part 17 of the claim form givesyou more information.

Other help – continued

Housing BenefitHousing Benefit is paid by local councils to people who need help to pay theirrent. Housing Benefit is not paid to help with the cost of mortgage interestpayments.

Council Tax BenefitYou may be able to get Council Tax Benefit from your local council to helpwith paying your council tax.

You can find out more about these benefits from your Jobcentre Plus orsocial security office.

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For information about your own claimGet in touch with your Jobcentre Plus or social security office. You canfind the phone number and address on the advert in the businessnumbers section of the phone book. Look under Benefits Agency.

For general information about this benefitRing the Benefit Enquiry Line for people with disabilities. The number is0800 88 22 00. The person you speak to will be able to give you generaladvice about the benefit and they can tell you about otherorganisations that may be able to help you.

If you have problems with hearing or speaking and use a textphone,ring 0800 24 33 55. If you do not have your own textphone system, theyare available in some libraries and Citizens Advice Bureau.

Where to get help and advice

Part of the Jobcentre Plus network, Department for Work and Pensions

Social Security Office

Pension IncomeWe will look to see if you have a pension income.

We use pension income to mean money you have coming in from oneof the following pensions

● occupational pension

● personal pension

● public service pension

● stakeholder pension

● a pension from a self-employed pension scheme

● permanent health insurance payments arranged by an employerwhere the contract of employment has ended.

Your pension will be managed by a pension provider. This is usually anorganisation like a former employer or insurance company.

If you have a pension income before tax of over £85.00 a week, yourIncapacity Benefit and any Incapacity Benefit you are claiming foranyone else, will decrease.

How your money is worked out – continued

Claiming for yourselfSect

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Marital status married widowed

single divorced

separated

Part 1 About you

Surname or family name

All previous surnames or familynames you have used. You shouldinclude your maiden name, anyprevious married names, or changesto family names.

Other names you use now – in full

Mr/Mrs/Miss/Ms

Address

Postcode

Daytime phone number if youhave one

Code Number

Daytime textphone number forpeople with speech or hearingproblems

Code Number

Date of birth / /

National Insurance (NI) numberYou can get this from your NInumbercard, letters from socialsecurity or payslips.This will help us deal with yourclaim more quickly.

Letters Numbers Letter

If you do not know your NInumber, have you ever hadone or used one?

No

Yes

What is this number?Please tick.

Home Work Mobile Fax

Please tell us about any other personal details you think we should know about inPart 18 Other information. For example, other names or recent previous addresses.

Please give us the address ofyour local Post Office for anyurgent payments we may needto make.

Postcode

Were you off workbecause of your illnessor disability for at least4 days in a row in the8 weeks before the dateyou are claimingIncapacity Benefit from?

No

Yes

Part 1 About you – continued

3

Are you claimingJobseeker’s Allowanceat a Jobcentre?

No

Yes Fill in your ES40 and send it back to the Jobcentre as soonas you can. This will help us to deal with your claim more quickly.

When this period of illness or disability began

What date do you want to claim Incapacity Benefit from?

What was the last date you● worked for an employer, or● worked as a self-employed

person, or● you claimed Jobseeker’s

Allowance, or● received National Insurance

(NI) credits because youattended a Jobcentre?

Did you work a nightshift which includedmidnight on the date youlast worked?

No

Yes What time did you start the shift? am/pm

What time did you finish the shift? am/pm

/ /

/ /

Fill in your E540 and send it back to the Jobcentre as soonas you can. This will help us deal with your claim morequickly

Are you receivingNational Insurance (NI)credits only, becauseyou attend a Jobcentre?

No

Yes

Do you have any special medical treatment?Special medical treatment is explained in page 1 ofthe SC1 Notes.

Do you work for anemployer?

No

Yes

No

Yes

Do not fill in this form. Get in touch with your employer and ask aboutStatutory Sick Pay (SSP).

Please fill in the rest of this form.

Are you a student? No

Yes

Have you been astudent in the 2 yearsbefore the date youare claiming IncapacityBenefit from?

No

Yes

Have you been on atraining course in the 2 years before the dateyou are claimingIncapacity Benefit from?By training we mean acourse you have taken tohelp you to find work.

Please send us any documents that show when you did thetraining and how much training allowance you were paid.This could be the certificate you were given at the end ofthe training. You must remember to send us all thedocuments we ask for. If you do not, benefit you can get because of this claim maybe delayed.We may write to you about your training allowance. Please fill in the rest of this form.

Have you been given aletter telling you thatyou are entitled to the52 week benefitprotection?

No

Yes

No

Yes

Part 1 About you – continued

4

Are you registered blindwith a local authority inEngland or Wales, orcertified as blind with aregional or islandscouncil in Scotland?

Please tell us the name of the local authority or council.

No

Yes

Part 2 About self-employment

5

Have you worked as aself-employed person inthe 21 weeks before thedate you are claimingIncapacity Benefit from?

Please tell us about this self-employed work.

What is your usual occupation?

Please go to Part 3.No

Please give brief details of the work you normally do.

Period of self-employment

Yes

From / /

How many hours a week do you normally work?

If your usual occupation has changed in the 21 weeksbefore this period of sickness began, please give details.

hours

To / /

Do you also work for anemployer?

No

Yes Please go to Part 3.

Are you a companydirector?

No

Yes Please go to Part 3.

Please go to Part 4.

Part 3 For unemployed people and people who work for an employer

What is your usual occupation?

Have you worked for anemployer in the 21 weeksbefore the date you areclaiming IncapacityBenefit from?

No

Yes Please tell us about this.


Employer 1

Postcode

Employer’s name and address

Job title

What were the main activitiesof the job?

Period of employment From / /

Hours worked each week hours

To / /

Employer 2

Postcode


Job title



To / /

6

Have you been given aStatutory Sick Pay Leaver’sStatement, SSP1(L) by yourlatest employer?

No

Yes Please send your SSP1(L) to us with this claim form. You must remember to send us all the documents we askfor. If you do not, benefit you can get because of this claimmay be delayed.


Employer 3

Postcode


Job title



To / /

If you worked for more than 4 employers in the 21 weeks before this period ofsickness began, tell us about the other employers in Part 18.

Employer 4

Postcode


Job title



To / /

7

Part 3 For unemployed people and people who work for an employer – continued



Part 4 About your illness or disabilityDetails of your illness or disability

Please give brief details ofyour illness or disability.We need to know what iswrong with you and how thisstops you from working.

Have you been inhospital as an in-patientsince your illness ordisability began?

No

Yes

Name and address of thehospital

Date you went into hospital

Have you come out ofhospital?

No

Yes Date you came out of hospital

Postcode

/ /

/ /

8

Please tell us about this.

Do you think your illnessor disability is because ofan accident at work whileworking for an employer?

No

Yes You may be able to get Industrial Injuries DisablementBenefit. We will send you leaflet SD7 Disabled because ofan accident at work? to read This will tell you about thebenefit and how to claim it.

Are you expecting a baby? No

Yes What date is your babyexpected?

/ /

Have you had a baby inthe 26 weeks before thedate you are claimingIncapacity Benefit from?

No

Yes What date was your babyborn?

/ /

Do you think your illnessor disability is because ofan industrial diseasecaused by conditions atwork while working foran employer?If you are not surewhether the disease youhave is an industrialdisease, tick Yes.

No

Yes You may be able to get Industrial Injuries DisablementBenefit. We will send you leaflet SD7 Disabled because ofan accident at work? to read. This will tell you about thebenefit and how to claim it.We will also send you leaflet SD6 Ill or disabled because ofa disease or deafness caused by work? to read, which willtell you about prescribed diseases.

Part 4 About your illness or disability – continued

Going back to work

Do you know when youwill be well enough towork again?

No

Yes


What date will you go back to work?

Will you go back to workon a night shift whichincludes midnight?

No

Yes What time will you start the shift? am/pm

What time will you finish the shift? am/pm

/ /

9

Have you been abroad at any time during the 5 years before the date you are claiming Incapacity Benefit from?Tick No, if you wentabroad just for a holiday.

No

Yes Which countries did you go to?


Tick the description thatapplies to your time abroad.

I worked for an overseas employer

I worked for a UK employer

I was self-employed

I was getting money from a social security scheme ofthe country I was staying in

Other – please give details below

We need to know about time you have spent abroad.

We use abroad to mean any country outside the United Kingdom (UK). The UK isEngland, Scotland, Wales and Northern Ireland, including territorial waters next tothe UK. But the UK does not include the Isle of Man or the Channel Islands.

Part 5 About time you have spent abroad

About your doctor

Please tell us the name andaddress of the doctor who issigning your medicalcertificates.

Postcode

Part 6 About other benefits and entitlements

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Are you getting any otherbenefits?Tick Yes, if you are waitingto hear about a benefit.For example,● Income Support● Jobseeker’s Allowance● Retirement Pension● Widow’s Benefit● War Widow’s Pension● Unemployability

Supplement● Training Allowance● Guardian’s Allowance● Bereavement benefits

Tick No, if you just getChild Benefit. We will askyou about this later in theform.

No

Yes Please tell us about the benefits below.

Name of benefit

Reference number, if known

Name of benefit


£ every

Name of benefit


Have you been paid anyStatutory Maternity Pay(SMP) by an employer?

No

Yes If this has now stopped,please give the date ofthe last payment.

/ /

Have you qualified for adisability element ofWorking Tax Credit,whether or not it is paid?

Have you ever madea claim for Carer’sAllowance?Tick Yes, if your claimwas disallowed.

No

Yes Please tell us the dateyou made this claim.

/ /

Are you, or yourpartner getting orwaiting to hear aboutPension Credit?

No

Yes Please tell us how much is paid and how often.

No

Yes

Did you get DisabledPerson’s Tax Credit inthe 2 years before6 April 2003?

No

Yes What period was it awarded for?

From / / To / /

Part 6 About other benefits and entitlements – continued

Are you getting thehighest rate carecomponent of DisabilityLiving Allowance?

No

Yes

Have you claimedDisability Living Allowancebut not yet heard if youwill get it?

No

Yes

Are you getting IndustrialInjuries DisablementBenefit?

No

Yes

Are you getting a WarDisablement Pension?

No

Yes

11

Is anyone getting extramoney added onto theirsocial security benefitfor you?Tick Yes, if anyone iswaiting to hear aboutgetting extra moneyadded onto their socialsecurity benefit for you.

No

Yes Please tell us about the person who is getting, or waiting tohear about getting, this extra money.

Their surname

Other names

Address

National Insurance (NI) number

Please tell us which benefits they are getting or waiting to hear about.

Postcode


Have you been gettingWorking Tax Credit orChild Tax Credit at ahigher rate than thefamily element, up to theday before the date youare claiming IncapacityBenefit from?Tick Yes, if you are notsure of the dates.

No

Yes

Part 7 Pension income

12

We need to know about any pension income that you have as it mayaffect the amount of benefit you can get.

For information on pension providers, pension income and how it mayaffect you, please read the notes we sent you with this form.

Do you have any pension income? No

Yes

Do you get any pension paymentmade to you as a beneficiary fromthe death of a member of apension scheme?

No

Yes Please give details below.

Are you waiting to hear aboutany pension income?If Yes, let us know as soon asyour pension income has beenawarded.

No

Yes

Name and address of the pensionprovider

Postcode

The pension provider’s phone number Code Number

How much is the pension after anydeductions?

£

How much pension is due to youbefore any deductions?

£

Your first (or only) personal pension income

Please tell us the name andaddress of your pension provider

Please tell us your pension provider’sphone number

Postcode

What is your pension referencenumber?

Code Number

How often is your pension paid?For example weekly, four-weekly,monthly, quarterly.

Part 7 Pension income – continued

13

When will you get the first paymentwhich includes the change?For example 15 May,

How often is your pension paid?For example weekly, four-weekly,monthly, quarterly.

When is the amount of yourpension due to change? For example 1 May,

How much pension are you paidafter any deductions?

£

How often is your pension paid ?(for example weekly, four-weekly,monthly, quarterly)

When is the amount of yourpension due to change?For example 1 May,

How much pension is due to youbefore any deductions?

£

How much pension are you paidafter any deductions?

£

Your second personal pension income

Please tell us the name andaddress of your pension provider

Please tell us your pension provider’sphone number

Postcode

What is your pension referencenumber?

Code Number

When will you get the first paymentwhich includes the change?For example 15 May,

Part 7 Pension income – continued

14

You can use this space to tell us if youhave any other pension income, oranything else you think we mightneed to know about your pensionincome.For example, give the reason andamount for any deductions that aretaken from your pension income.

Important – please send us proof of your pension income,this could be one of the following● a letter of entitlement from your employer or insurance company

who pay the pension● a payment advice notice from your pension payer● a wage slip or P60 showing details of your pension income.Failure to do so may affect your claim.

Have you contributed more thanhalf the premiums towards anypermanent health insurancepayment?

No

Yes Please give details below.

Name and address of the employerpaying the remaining premium

Postcode

Their phone number Code Number

Has your contract of employmentended with this employer?

No

Yes When did it end? / /

Permanent health insurance

Part 8 Tax informationIf you qualify for Incapacity Benefit, it may affect the amount ofincome tax you have to pay.

For more information on Income Tax, get leaflet IR144 Income TaxIncapacity Benefit from your nearest Inland Revenue enquiry centre.Look for Inland Revenue in the business numbers section of the phonebook.

Your answers to these questions will not affect whether you getIncapacity Benefit, but they will help us to try to make sure you aregiven the right tax code and that you pay the right amount of tax.

15

Tax district and tax reference numberYou can find this above your NInumber on Inland Revenue tax forms.Or you can ask your employer or yourpension provider. If you do not knowyour tax reference number, send thisform back to us straight away.

Please send us your form P45, if you have one.

While you are off work dueto your illness or disability,will your present or formeremployer pay you?

No

Yes

If you are self-employed willyour business now stopbecause or your illness ordisability?

No

Yes

Blind person’s allowanceTick this box if you are

● registered blind with a localauthority in England or Wales, or

● certified as blind with a regionalor islands council in Scotland

and you want to claim thisallowance.

No

Yes Please tell us the name of the local authority.

Claiming extra benefit foranother adultSe

ctio

n 2

Claiming extra Incapacity Benefit for an adultIf you want to claim extra Incapacity Benefit for● your husband or wife, or● someone who looks after children for youplease complete Parts 9 to 14 and Part 16 of this section.

If you are claiming for a partnerFrom April 2004 there is a change in the rules if you are claiming anincrease of Incapacity Benefit for your partner.By partner we mean someone you are married to and living with or aperson you live with as if you are married to them.

We may need your partner to go to a work focused interview with apersonal adviser.

Your partner will not have to go to a work focused interview unlessyou have been claiming Incapacity Benefit for 26 weeks or more. Wewill let them know if they have to go.

If your partner does not take part in the work focused interviewwithout good reason your benefit may be affected.

If you want to claim extra Incapacity Benefit for a person you employto look after children for you, please complete Parts 10 and 15 of thissection.

Child Tax CreditFrom 6 April 2003 you cannot claim an increase for children but youcan claim Child Tax Credit instead. To find out more about Child TaxCredit visit www.inlandrevenue.gov.uk/taxcreditsYou can claim online too.

You can also phone the Inland Revenue by calling the Helpline on thefollowing numbers:England, Scotland and Wales – 0845 300 3900Northern Ireland only – 0845 603 2000

Textphone for people with hearing or speech difficulties:England, Scotland and Wales – 0845 300 3909Northern Ireland only – 0845 607 6078

Lines open 8am–8pm seven days a week (except Christmas Day, BoxingDay, New Year’s Day and Easter Sunday).

If you need help or a form in Welsh, please phone 0845 302 1489.Lines are open 8.30am–5pm Monday to Friday.

We will need some information about the children before we can payextra money for an adult.

If you do not have any childrenYou may be able to get extra Incapacity Benefit for your husband orwife if they are aged 60 or over. They will not need to go to a workfocused interview.

If you do not want to claim extra benefit please go to Part 16.

16

Please tell us about your husband or your wife or theperson who looks after children for you.

Their surname

Their other names

Mr/Mrs/Miss/MsTheir title

Their date of birth

Their National Insurance (NI) number


/ /

17

Part 9 Claiming extra money for your husband or wife or a person who looks after children for you

Is the person in hospitalat the moment?

No


No

Yes


Please complete Parts 9 to 16 of this form.

Name and address of the hospital

Date they went into hospital

Do they normally liveat a different addressto you?

No


Their address

£

How much do you sendeach week?

Postcode

Postcode

/ /

What date did you startmaking these payments?

/ /

Do you sendany money tothis person?

No

Yes

18

Do you want to claim extra money for● your husband, or● your wife, or● a person who looks after

children for you?

Is your husband or wifeor the person who looksafter children for you,living with you now?

No

Yes

If you claim extra money for a partner who lives withyou and is under 60 years of age, they may have to goto a work focused interview once you have beengetting Incapacity Benefit for 26 weeks or more.

We need to see● your marriage certificate, and● the birth certificate of your husband or wife.Please send the certificates to us with this form, if you have them. We will sendthem back to you as soon as we can. If you do not have the certificates, we willwrite to tell you what to do. But do not delay sending back this form.

If you want, you can bring the certificates to our office. We will give thecertificates straight back to you after we have seen them.

Remember● we need to see the real certificates, not photocopies● if you do not send us all the documents we ask for, benefit you can getbecause of this claim may be delayed.

Part 9 Claiming extra money for your husband or wife or a person who looks after children for you – continued

If you are claiming for your husband or wife

Are you sending yourmarriage certificate withthis form?

No

Yes

Are you sending thebirth certificate of yourhusband or wife withthis form?

No

Yes

If you have ticked No to eitherof these questions, please saywhy you cannot let us see thecertificate or certificates.

19

Part 10 Claiming extra Incapacity Benefit for an adult


Are you or anyone wholives with you gettingChild Benefit?

Before we can pay extra money for your husband or wife orthe person who looks after children for you, we need toknow details of the child or children and Child Benefit.

No

Yes

20

Child 1

Child’s surname

Child’s other names

Child’s date of birth

Are you this child’sparent?

No

Yes

Please tell us who is gettingChild Benefit.

/ /

You

Your husband or wife who liveswith you

Your husband or wife whodoes not live with you

Your ex-husband or ex-wife

Not known

Someone who looks afterchildren for you

You will find the reference number on letters we have sentyou about Child Benefit, or on the front cover of your orderbook.

If you have more than one book, please tell us both thereference numbers.

Please tell us about each child. If you need to tell us aboutmore than 3 children use the space in Part 18.

£

Amount each week Reference number

£

Amount each week Reference number

Part 10 Claiming extra Incapacity Benefit for an adult – continued

21

Child 2

Child’s surname




No

Yes

/ /

Child 3

Child’s surname




No

Yes

/ /

Please tell us about any changes there are likely to be in the next 2 months thatmight make a difference to the amount of Child Benefit that is being paid.For example, if a child is leaving school.

The changes you must tell us about are listed in● the notes we sent to you

if your Child Benefit is paid direct into an account, or

● the coloured pages of a Child Benefit order book.

Are you, or your husbandor your wife, getting afamily benefit for a childfrom another country?

No

Yes

Part 11 If your husband or wife or the person who looks afterchildren for you works for an employer

Is your husband or wife,or the person who looksafter children for you,working for anemployer?

No

Yes Please tell us about each employer.

Employer 1


Payroll, staff or other referencenumber

Please send us their payslipsthat cover the previous 5 weeks. You must rememberto send us all the documentswe ask for. If you do not,benefit you can get because ofthis claim may be delayed.

£ a weekWhat are their weekly earningsafter income tax and NationalInsurance (NI) contributions aretaken off?Include● earnings or fees as a director● maternity pay● holiday pay● bonus payments.


Postcode

22

Please tell us about any itemsor services the employerprovides. For example, specialclothing.

Please give details of theweekly amount of anyexpenses connected with theirwork. Do not include travellingexpenses to and from theirplace of work.

Is payment of WorkingTax Credit included inthe earnings?

No

Yes Please tell the weekly amount £ a week

Employer 2


Payroll, staff or other referencenumber

£ a weekWhat are their weekly earningsafter income tax and NationalInsurance (NI) contributions aretaken off?Include● earnings or fees as a director● maternity pay● holiday pay● bonus payments.

Please tell us about any itemsor services the employerprovides. For example, specialclothing.

Postcode

Please give details of theweekly amount of anyexpenses connected with theirwork. Do not include travellingexpenses to and from theirplace of work.

Is your husband or wife,or the person who looksafter children for you,off work because of anillness or disability,maternity leave or atrade dispute?

No

Yes

Are they getting anypayments from theiremployer while theyare off work?Include● maternity pay● Statutory Sick Pay (SSP)● Statutory Maternity Pay (SMP).

No

Yes

/ /What date did they last work?

£ a week

How much are theygetting each week?


If you need to tell us about more than 2 employers, use the space in Part 18.

Part 11 If your husband or wife or the person who looks afterchildren for you works for an employer – continued

23

Please send us their payslipsthat cover the previous 5 weeks. You must rememberto send us all the documentswe ask for. If you do not,benefit you can get because ofthis claim may be delayed.

Is payment of WorkingTax Credit included in theearnings?

No

Yes Please tell the weekly amount. £ a week

Is your husband or wife, or the person who looksafter children for you,self-employed?Tick Yes, if they own abusiness or they have ashare in a business.This includes your business,if you have one.

No

Yes

What is the name and address of the business?

How much profit has the business made for the lastcomplete business year?By profit, we mean any profit, gain or other emolumentsthat have been agreed for income tax purposes.

£


If you are self employed,does your husband or wife, or someone wholooks after children for you, help in your business?

No

Yes

Do you pay yourhusband or wife, orsomeone who looksafter children foryou, a wage?

No

Yes What are their weeklyearnings after income taxand National Insurance(NI) contributions aretaken off?


£ a week

Is a charge madefor their servicesagainst the profitsfrom your businessfor income taxpurposes?

No

Yes What is the weekly charge?

£ a week

Postcode


Part 12 If your husband or wife or the person who looks after children for you is self-employed

24

Part 13 About other money coming in

Does your husband orwife, or the person wholooks after children foryou, have any othermoney coming in?Do not tell us about othersocial security benefits, anoccupational pension orpersonal pension. We willask you about these laterin the form.

No

Yes What is this money?

How much do they get each week?Please tell us the average weekly amount if the money isnot the same each week.

Who pays the money?

What is their address?

Does your husband or wife, or the person wholooks after children for you, have any boarders or lodgers?

No

Yes

Does this payment includean amount for heating?

No

Yes

If you need to tell us about more than 3 boarders, use thespace in Part 18.

How much does each boarder or lodger pay each week?

Boarder 1

Boarder 2

Boarder 3

Postcode


25

£

£ a week

£ a week

£ a week

Part 14 About occupational and personal pensions

Does your husband orwife, or the person wholooks after children foryou, get an occupationalpension or a personalpension?

No

Yes

Pension 1

Name and address of thepension payer

Phone number of the pensionpayer

What is the pension referencenumber?

£How much pension do they getafter income tax is taken off?

How often is the pension paid?

What day or date are theysupposed to be paid?For example, this could beevery Friday or the last workingday of each month.

Type of pension

Postcode


Please tell us about each pension.

Pension from an employer

Pension from a self-employed pension scheme

Personal pension

26

Code Number

Part 14 About occupational and personal pensions – continued

If you need to tell us about more than 2 pensions, use the space in Part 18.

Pension 2

Name and address of thepension payer

Phone number of the pensionpayer

What is the pension referencenumber?

£How much pension do they getafter income tax is taken off?

How often is the pension paid?

Type of pension

Postcode

Pension from an employer

Pension from a self-employed pension scheme

Personal pension

Code Number

What day or date are theysupposed to be paid?For example, this could beevery Friday or the lastworking day of each month.

27

Part 15 Claiming extra money for someone who does not livewith you but you employ to look after children for you

Do you want to claimextra money for aperson who does notlive with you and youemploy to look afterchildren for you?This could include anorganisation you mayemploy to look afterchildren for you.

No

Yes


What is their name and address?

£ a weekHow much do you pay theperson or organisation wholooks after children for youeach week?

Please give details of anyexpenses you have inconnection with the careof your children.

28

Postcode

What date do you want toclaim extra money from?

/ /

Part 16 About benefits and state pensions

Benefit 1

Name of benefit

Who is the benefit paid to?

Benefit reference numberThis is on the front of the orderbook or on letters about thebenefit.

If you need to tell us about more than 2 benefits, use the space in Part 18.

Any money paid by the Department for Work and Pensions orany other government department to● your husband or wife, or● a person who looks after children for youmay affect the amount of the extra Incapacity Benefit that youcan get.

And money paid to another person for you or anyone you areclaiming for may also affect the amount of the extraIncapacity Benefit that you can get.

Please tell us about this money below. Include benefits, statepensions or allowances from the Department for Work andPensions or any other government department. But do notinclude any Child Benefit you have already told us about on thisform.

£ a weekHow much is paid each week?

Which office deals with thebenefit?

Benefit 2

Name of benefit

Who is the benefit paid to?

Benefit reference numberThis is on the front of the orderbook or on letters about thebenefit.

£ a weekHow much is paid each week?

Which office deals with thebenefit?

29

More information we needSect

ion

3

30

Part 17 Making payments to you

A – Payment direct into an account

This section asks for the information we need to pay your Incapacity Benefit.

Our policy is to pay all benefits directly into an account. This is the safestway to pay you and lets you choose how and when you get your money.You can use a bank or building society account. You may be able to use acash machine, which will usually mean you can get your money at any timeof the day or night. The Post Office® also provides a bank account that wecan pay benefits into. With this account you can only collect your money incash from Post Office branches. There are arrangements with a number ofmajor banks and building societies so that you can collect cash from some oftheir accounts at your local Post Office.

We recommend that you get your money in this way because● it is safe and secure ● it is convenient – you decide when and how much you want to withdraw ● using an account may help you to save ● from some accounts you could have regular bills paid. This could save you

money but you will need to make sure that there is enough money in youraccount to pay the bills. If not, you may be charged a fee

● you can get your money from many different places.

The account can be● in your name, or● in the name of your partner.

We use partner to mean the person you are married to or the person you livewith as if you were married to them, or

● in both the names of yourself and your partner, or● in the name of the person acting on your behalf, or● in both the names of yourself and the person acting on your behalf.

Restricted arrangements apply for the Post Office® card account (see section C).

You can be paid every 2 weeks, every 4 weeks or every 13 weeks.

If you choose to be paid every 2 weeksThe money will be paid into an account for you on the last bank working day ineach 2-week period.

If you choose to be paid every 4 weeksThe money will be paid into an account for you on the last bank working day ineach 4-week period. Your first payment might cover a period of 2 to 5 weeks,but after this all payments will cover a 4–week period.

If you choose to be paid every 13 weeksThe money will be paid into an account for you on the last bank working day ineach 13-week period. Your first payment might cover a period of 2 to 14 weeks,but after this all payments will cover a 13–week period.

Finding out how much is paid into the accountWe will tell you when the first payment will be made and how much it is for.After that, we will pay the same amount into your account unless we tell youotherwise.

Part 17 Making payments to you – continued

A – Payment direct into an account continued

B – How I would like my money paidTick this box to confirm that you agree to have your Incapacity Benefit paiddirectly into an account and that you have read and understood the notesabout being paid this way. Tell us about your account below.

Tick this box if you do not have an account or you have an accountbut are unwilling to use it. Then go to section C of this form.

In your name, orShould the account bePlease tick one box toshow the account youwish to use.

Please note – if you have chosen an account of the person acting on your behalf, or an accountin your name and the person acting on your behalf, by ticking the appropriate box, this meansyou are confirming that you will authorise them to use the money for you as you tell them.

In the name of your partnerWe use partner to mean the person you are married to orthe person you live with as if you were married to them, or

In both the names of yourself and your partner, or

In the name of the person acting on your behalf, or

In both the names of yourself and the person actingon your behalf.

How often do you wantyour benefit to be paid? Every 2 weeks

Every 4 weeks

Every 13 weeks

31

You can check your benefit payments on your account statements. Yourstatements may show your National Insurance (NI) number next to payments thatare from us. If you think your payment is wrong, get in touch with your JobcentrePlus or social security office.

If not enough money is paid into the accountWe will make another payment to you or add the money we owe you onto yournext payment. We will contact you to tell you what we are going to do.

Sometimes too much money may be paid into your account.If this is because of the way the system works for payments direct into an account,we have the right to claim back any money you are not entitled to. For example,you may give us information which means you are entitled to less money and it isnot possible or practicable to change the amount already sent out for payment.We will always tell you in writing if we claim back money under this rule.

Getting someone to collect your benefitIf you want someone else to collect your benefit for you regularly, you may beable to make arrangements with your bank, building society or, if you have aPost Office® card account, the Post Office. Please ask them to help you with this.

32


B – How I would like my money paid continued

1 What name or names is the account in?Please write the name or names as they appear on the chequebook, passbook orstatement.

2 Full Name of bank or building societyPrint the full name of your bank or building society.For a Post Office® card account insert the words Post Office.

3 Sort CodePlease tell us all six numbers, for example: 12-34-56.

4 Account numberThis is 7 to 10 numbers long.

Tell us about the account you would like your benefit paid into. You will find the account details on your chequebook, passbook or statements.

Payments can be made into most bank or building society accounts, but notmortgage accounts.

Not all accounts are accessible at the Post Office. If this is important to you,please remember to ask your bank or building society whether you can useyour account at the Post Office.

If you are unsure about any details, ask your bank, building society, orPost Office (for those with a Post Office® card account).

5 Building Society roll or reference number – some building societies accounts use a roll orreference number. The number is on the passbook. If you are not sure if the account has aroll or reference number, ask the building society.The roll or reference can contain letters and numbers and can be up to 18 characters long.

More information if it is a building society account

Please make sure that you have completed all the account details on this form.

33


C – If you are unable or unwilling to complete section BIf you do not have a suitable bank or building society account or you areunwilling to use an existing account, for example a joint account, any bank orbuilding society will help you open an account that suits you better.Remember to ask whether their accounts allow you to get your money fromthe Post Office, if this is important to you.

● Basic bank accountsIf you have had problems opening an account, or if you are worried aboutbeing overdrawn, you could ask about opening a basic bank account. Theseare sometimes called introductory or starter accounts and are availablefrom all major banks. These accounts offer free banking but overdrafts arenot available. You can use these accounts to pay money in, pay billsautomatically and get cash out. Most basic bank accounts also allow you toget cash from Post Offices.

If you do not want to use one of the above accounts, you may want toopen a Post Office® card account.

● Post Office® card accountThis is a simple bank account that can only have benefit and tax creditpayments paid into it. You can only collect payment from it in cash at aPost Office branch. You will not have a cheque book and cannot withdrawmoney at a cash machine. You will not be able to run up an overdraft, paybills by Direct Debit or Standing Order, or have your salary or any othermoney paid in. The account can only be in your name. You may be able toarrange with the Post Office for someone else to collect your benefitregularly from this account.

● I am opening a bank or building society account orI am going to open one

● I want more information about opening abank or building society account or a PostOffice® card account

● I do not agree to having my money paid directinto any type of account

Complete the claim form and send it to us now. Do notwait until you have opened an account.

Once you have opened an account, please let us know youraccount details as soon as possible.

We will contact you at a later date.

What to do now

Tick the box that applies to you.

Part 18 Other information

You can use this space to tell us anything else you think we might need to know.

34

35

Part 19 For people signing this form for someone else

Please tell us why you aresigning this form for someoneelse.

Please tell us about yourself.

Your full name

Your address

Code NumberDaytime phone number

Relationship, if any

Postcode

Mr/Mrs/Miss/Ms

What is this number?Please tick.

Home Work Mobile Fax

36

Part 20 Declaration● I understand that if I give information that is incorrect or incomplete, action

may be taken against me.

● I declare that the information I have given on this form is correct andcomplete.

● I declare that where I have given, or intend to give, information so thatmy benefit can be paid directly into an account, I have read andunderstood the notes in part 17 of this form.

● I agree to my benefit being paid direct into the account nominated and tothe Department’s right to recover overpayments as described in part 17 ofthis form.

● I understand that I must promptly tell the office that pays my benefit ofanything that may affect my entitlement to, or the amount of that benefit.

Under section 16 of the Social Security Fraud Act 2001, it is an offence tofail to notify a change of circumstances promptly. Failure to tell us about achange in your circumstances promptly may result in action being takenagainst you.

● I agree that – the Department for Work and Pensions– any doctor advising the Department– any organisation with which the Department has a contract for the

provision of medical services may ask any of the people or organisations mentioned on this form for anyinformation which is needed to deal with– this claim for benefit– any request for this claim to be looked at againand that the information may be given to that doctor or organisation or tothe Department.

● I also understand that the Department may use the information which ithas now or may get in the future to decide whether I am entitled to– the benefit I am claiming– any other benefit I have claimed– any other benefit I may claim in the future.

● I agree to my doctor, or any doctor who has been treating me, beinginformed about the Secretary of State’s determination on incapacity forwork.

This is my claim for Incapacity Benefit.

Signature

/ /Date

37

Part 21 What to do nowPlease make sure that you● have answered all the questions on this form that apply to you,

and● you have signed and dated this form, and

● check you are sending all the documents we have asked for.Use the check list below.

Send this form and any documents we have asked you for to yoursocial security office.

Do not delay or you could lose money. If you wait you could losemoney. Please note that benefit cannot be paid for a period morethan 3 months before the date we receive your claim.

Part 22 What happens nextIf you can get Incapacity Benefitwe will write and tell you● how much you can get● more about the benefit.

Benefit you may get because of this claim will be paid morequickly if you● answer all the questions on this form that

apply to you and your partner, if you have one● send us all the documents we ask for.

If you cannot do this, get in touch with us straight away. If youdo not, you may lose benefit.

If you cannot get Incapacity Benefitwe will write and tell you the reason.

Part 23 Where to get help and adviceFor information about your own claimGet in touch with your social security office. You can find thephone number and address on the advert in the business numberssection of the phone book. Look under Benefits Agency.

For general information about this benefitRing the Benefit Enquiry Line for people with disabilities and theircarers. The number is 0800 88 22 00. The person you speak to willbe able to give you general advice about this benefit and theycan tell you about other organisations that may be able to helpyou.

If you have speech or hearing problems and use a textphone, ring0800 24 33 55. If you do not have your own textphone system,they are available in some libraries and Citizens Advice Bureau.

38

Part 25 How we collect and use informationThe Department for Work and Pensions collects information for socialsecurity, child support, vaccine damage, employment and trainingpurposes. The information we collect about you will depend on thenature of your business with us but may be used for any of theDepartment’s purposes.

We may check information provided by you, or information about youprovided by a third party, with other information held by us. We mayalso get information about you from certain third parties, or giveinformation to them, to check the accuracy of information, to preventor detect crime, or to protect public funds in other ways, for researchand statistical purposes, as permitted by law.

These third parties include other government departments, localauthorities, and private sector bodies such as banks and organisationsthat may lend you money.

We will not disclose information about you to anyone outside theDepartment unless the law permits us to. The Department is the DataController for the purposes of the Data Protection Act. If you want toknow more about what information we have about you, or the way weuse your information, you can contact any of the Department’s officesand ask for the leaflet GL33 Data Protection Act 1998 – It affects you.Or you can find a copy of the leaflet on our website. The address iswww.dwp.gov.uk

Part 24 Check listBefore you send in this form, please read the following list. Tick the boxes to show which documents you are sending.

SSP1(L)

P45

Your birth certificate

Proof of yourpension income

Partner’s birth certificatePartner’s payslip

Marriage certificate

Details of your trainingcourse (see page 2)

39

For official use

Date of marriage

Spouse’s maiden name

Spouse’s date of birth

Nature of evidence

Verified by

Checked by

Certificate(s) returned by

on (date)

Part of the Jobcentre Plus network, Department for Work and Pensions

Social Security Office

your claim for incapacity beneﬁt - the national...

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