For people who are or have been
self-employed, a subcontractor or
a company director
Please answer all the questions that apply to you or your partner, if you have one.
If you do not, any payment could be delayed.
B16 10/13
Do you have a partner who is living with you?
No
We use partner to mean
l a person you are married to or a person you live
with as if you are married to them, or
Yes
You and your partner, if you have one, must
fill in all parts of the form that apply to you.
l a civil partner or a person you live with as if you
are civil partners.
You Your partner
Surname or family name
All other names, in full
Date of birth
Letters Numbers Letter
Letters Numbers Letter
National Insurance (NI) number
You can find this on your National Insurance (NI)
numbercard, letters from the Department for Work
and Pensions or payslips.
Address
Tell us your address. And tell us your partner’s
address if it is different to yours.
Postcode
Daytime phone number
Code Number
Code Number
2
Part 1: About you
13-Sep-13
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You Your partner
Are you or your partner self-employed?
No No
Yes
Yes
On what date did you or your partner
become self-employed?
%
Please send us details of your income and Please send us details of their income and
expenses for the last 13 weeks. expenses for the last 13 weeks.
No
Are you or your partner a share fisherman?
No
Yes Yes
No
Do you or your partner own a boat?
No
Yes Yes
What is your or your partner’s percentage share
%
of the catch?
Do you or your partner run a farm or croft?
No
Yes
Have you or your partner been in touch with the
No No
Agricultural Development and Advisory Service
Yes Yes
about subsidies?
Please send us any details about this. Please send us any details about this.
What trade or business are you or your partner
involved in?
For example, a shop or restaurant.
Name and address of the business
Postcode
When did the business start?
3
No
Yes
Part 2: About the business
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13-Sep-13
Yes
Part 2: About the business continued
You Your partner
Have you or your partner stopped trading?
Yes
No
Yes
No
Date trading stopped
If you or your partner have stopped trading please
say why. For example, are you temporarily without
work or sick?
If you or your partner have stopped work because of
illness please say when you hope to return to work.
Are you or your partner the director of a company?
No No
Yes Yes
Is anyone running the business in your or
No No
your partner’s absence?
Yes
Has any money been received into the business
since you or your partner last worked?
How much has been received?
When was it received?
Please list any business expenses paid out to earn
the amount received
No
Yes
£
No
Yes
£
4
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13-Sep-13
Part 2: About the business continued
You Your partner
Is the business regarded as a going concern by
yourself, your bankers, accountant and creditors?
Yes
No
Yes
No
Do you or your partner have reasonable prospects
of more work in the business in the near future?
Yes
No
Please tell us why in Part 5.
Yes
No
Please tell us why in Part 5.
When do you hope to start work again?
Do you or your partner hope to resume work in the
business when economic conditions improve?
Yes
No
Yes
No
When do you expect this to be?
Are you or your partner available for work and
looking for work in any other field of employment
during this break in employment?
Yes
No
Yes
No
If you are not available for other work or looking
for other work, please tell us why.
Are you or your partner still regarded
as self-employed by these people?
HM Revenue and Customs
VAT
HM Revenue and Customs
VAT
(National Insurance contributions) (National Insurance contributions)
5
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13-Sep-13
Part 2: About the business continued
If the business is in decline or has temporarily
stopped, do you or your partner consider this to be
the normal pattern of work?
You Your partner
No
Please say why below.
No
Please say why below.
Yes
Please say why below.
Yes
Please say why below.
How long is the break between contracts or
jobs normally?
How many hours a week on average were you or
hours a week hours a week
your partner working before you claimed benefit?
How many hours a week on average are you or
hours a week hours a week
your partner working as self-employed now?
Are you or your partner currently undertaking any
activities in connection with self-employment?
Include any time spent
l visiting potential customers
l purchasing, ordering or selling stock
l canvassing for work
l giving estimates
l travelling in connection with work but not to or
from work
l advertising
l supervising or managing
l on research or practising
l cleaning
l maintaining capital assets
l doing the accounts.
No
Yes
Please tell us about this below.
No
Yes
Please tell us about this below.
How long do you or your partner spend
hours a week hours a week
on these activities?
6
days / weeks / months
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13-Sep-13
Part 3: About business assets
You Your partner
Do you or your partner own any business assets?
No No
For example, property, vehicles, stock, tools,
machinery and so on.
Yes
Please list the assets and their value:
Yes
Please list the assets and their value:
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
If you or your partner do not intend to start
trading again, do you intend to sell the
business assets?
Yes
No
Please tell us about this below.
Yes
No
Please tell us about this below.
If No, tell us why you are not going to sell the assets.
Business assets may affect the amount of benefit
you can get.
How long do you think you or your partner
need to sell the business assets?
7
days / weeks / months
days / weeks / months
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13-Sep-13
Part 3: About business assets continued
You Your partner
What action have you or your partner
taken to sell the business assets?
Are any debts secured against the business assets?
No No
Yes
Yes
How much are the debts?
£ £
What are the debts for?
8
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13-Sep-13
Part 4: More about the business
You Your partner
Do you or your partner have a business account
No No
with a bank?
Yes Yes
How much is in the account?
£ £
Please send a statement from the bank or from Please send a statement from the bank or from
an accountant. an accountant.
Are you or your partner owed any money?
No No
Yes Yes
How much money is owed?
£ £
What is the money owed for?
Is the business in liquidation or receivership?
No No
Yes Yes
Name and address of the accountant or
insolvency practitioner
Postcode
Their phone number
Code Number Code Number
Can we ask the the accountant or insolvency
No No
practitioner to share information about the business
with us, if we need to contact them?
Yes
Yes
9
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13-Sep-13
Part 4: More about the business continued
You Your partner
Is there a profit and loss account for a
No No
12-month period ending within the last year?
Yes Yes
Please send it to us. Please send it to us.
Is there a trading account for a 12-month period
No No
ending within the last year?
Yes Yes
Please send it to us. Please send it to us.
No No
Are there any balance sheets for the last year?
Yes Yes
Please send them to us. Please send them to us.
Do you or your partner have an accountant?
No No
Yes Yes
Name and address of the accountant
Postcode
Their phone number
Code Number Code Number
Can we ask the accountant to share information
No No
about the accounts, if we need to contact them?
Yes Yes
If you do not have prepared accounts we may need to contact you again.
10
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13-Sep-13
Part 5: Other information
Please use this space to tell us anything else you
think we might need to know.
Continue on a separate sheet of paper, if necessary.
But make sure you sign and date it and write your
full name, address and National Insurance (NI)
number on it.
11
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13-Sep-13
Part 6: Your declaration
Joint claims for Jobseeker’s Allowance
If you have made a joint claim for Jobseeker’s Allowance either or both of you can sign
the declaration. Both of you are responsible for the information on this form.
You Your partner
I understand that
l if I knowingly give information that is incorrect or
incomplete, I may be liable to prosecution or other
action
l the information I have provided will be used to
process my claim. Some of the information may
be checked with other sources
l the information may be used for other purposes
relating to the work of the Department for Work
and Pensions. Some information may be given to
other government bodies as permitted by law.
I declare that the information I have given on this
form is correct and complete as far as I know
and believe.
What to do now
l Please make sure you send us everything we have
asked for with this form. If you cannot send
something we have asked for, tell us why in
Other information on page 11. But do not delay
sending us this form.
l Send this form back to us as soon as you can.
We may have to interview you if we need more
information.
l Make sure you and your partner, if you have one,
have signed and dated this form.
Signature
Date
Signature
Date
B16_102013_002_001
12
Please sign the form here after
printing
Please sign the form here after
printing
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13-Sep-13
Find your nearest office - internet link
We would like your feedback
about this PDF claim form
In this PDF form we have introduced a special feature that
lets you save it in Adobe Acrobat Reader 5.1 and later. This
means that you no longer have to complete the form in one
session.
We would like your feedback about this form so that we can
improve future versions.
Please email your comments to this email address:
forms.feedback@dwp.gsi.gov.uk
For help or advice on the information you need to put on the
form or about the benefit you want to claim, contact the
office that deals with the benefit.
If you are having technical difficulties:
• downloading the form
• navigating around the form
• moving from page to page, or
• printing a hard copy
Contact the eService helpdesk
Phone: 0845 601 80 40
Minicom (textphone): 0845 601 80 39
Email: eservicehelpdesk@dwp.gsi.gov.uk
Opening hours
Monday to Friday: 08:00am - 09:00pm
Weekend: 08:00am - 04:00pm
Closed on all Public and Bank Holidays
Thank you.
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