Fillable Esa1 ESA1 claim form for Employment Support Allowance

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Esa1 ESA1 claim form for Employment Support Allowance

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Employment and Support
Allowance
Claim form and notes about how to claim
ESA1 10/18
You can also claim by filling in this form in BLACK INK and in CAPITAL LETTERS
l Please read the notes before you fill in this form
l
Send the completed form back to us within one month of the date on the letter that came with this
claim form. If you don’t, you may only get benefit from the date we get all the information we need
l
Post it to us using the envelope that came with the form. It doesn’t need a stamp. Please note, it can
take 7 days to reach us by post
l You can also download and print off this form by typing ‘ESA1’ into the search field at
www.gov.uk
How to claim
The quickest and easiest way to make a claim is by phoning 0800 055 6688.
Our opening hours are Monday to Friday, 8am to 6pm.
l You won’t need to complete this form as our staff will call you back and talk you through the claim
l You can ask someone to be on the call with you. This could be a friend, relative or support worker
l If you find long calls difficult, you can take a break and we’ll call you back
Notes
for you to keep
What is Employment and Support Allowance?
If you have a disability, illness or health condition, Employment and Support Allowance (ESA) offers you:
l financial support if you’re unable to work
l personalised help to help you get into work when you’re able to or make steps towards going back to work
You can apply for ESA if:
l you have a disability, illness or health condition
l you’re unemployed
l you’re self-employed
l you’re employed but unable to get Statutory Sick Pay
l your Statutory Sick Pay has now ended
There are 2 types of ESA:
l contribution-based
l income-related
Contribution-based Employment and Support Allowance
You may get contribution-based ESA if you’ve paid or been credited with enough class 1 or class 2 National Insurance contributions in the last two
relevant tax years. You won’t get contribution-based ESA if you have credits only and not paid contributions. To check your National Insurance
record or read about National Insurance credits and contributions, visit the HM Revenue & Customs (HMRC)’ website at www.gov.uk/check-
national-insurance-record
As part of your claim to ESA, you’ll be asked to take part in a Work Capability Assessment. This will help us understand your current disability, illness
or health condition. Depending how much your disability, illness or health condition limits your ability to work, you will be placed into one of two
different groups. If you can show you’re able to start doing things to prepare for work in the future, you will be put into the work-related activity
group. If you are placed in the work-related activity group contribution-based ESA can only be paid for a maximum of 365 days.
Please make sure you read these notes as they will help you complete the right parts of the form
About this form
l If you need help completing the form, you can ask a friend, relative or an organisation that you know and trust to help you. You can also get
help by contacting Jobcentre Plus
l You may not get Employment and Support Allowance if you do not answer all the questions on the form that apply to you and your partner if
you have one
l If you can’t send us the information we have asked for, please tell us why in Part 23 Other information. Sometimes we may still be able to deal
with your claim
If you would like this claim form in Braille, large print or audio please call Jobcentre Plus on 0800 169 0310 or textphone 0800 169 0314 and tell
us what you need. Calls to 0800 numbers are free from landlines and mobiles.
If you live in Wales and want this form in Welsh please call us on 0800 328 1744. You can also download and print off this form in Welsh by
typing ‘ESA1’ into the search field at www.gov.uk
Notes for you to keep continued
You may get a lower amount of benefit if you or anyone you are claiming for has:
l savings over £6,000
l money coming in each week. For example
– earnings from part-time work
– other benefits
– your partner’s earnings
– personal or occupational pensions.
You won’t be able to get income-related ESA if your partner is working more than 24 hours a week or you have joint savings of more than £16,000.
Income-related Employment and Support Allowance
How much you could get depends on your situation. You can claim income-related ESA for:
l you and your partner
l some housing costs.
We use ‘partner’ to mean a person you live with who is your husband, wife or civil partner, or a person you live with as if you are a
marriedcouple.
As part of your claim to ESA, you’ll be asked to take part in a Work Capability Assessment. This will help us understand your current
disability, illness or health condition. Depending on how much your disability, illness or health condition limits your ability to work, you
will be placed into one of two different groups.
If you can show you’re able to start doing things to prepare for work in the future, you will be put into the work-related activity group.
If your disability, illness or health condition severely limits your ability to work, you will be put into the support group. There’s no time
limit on how long you can claim income-related ESA.
If your disability, illness or health condition severely limits your ability to work, you will be put into the support group. There’s no time limit on
how long you can claim contribution-based ESA if you’re in the support group.
You may get ESA if you’ve lived or worked abroad and paid enough UK National Insurance or the equivalent in a European Economic Area (EEA)
country, or a country with which the UK has an agreement.
You may get a lower amount of benefit if you get:
l other
benefits
l a personal or occupational pension
l a public service pension
Your savings will not affect your contribution-based ESA.
Notes for you to keep continued
Work Capability Assessments
As part of your claim to ESA, you’ll be asked to take part in a Work Capability Assessment. We will ask you to read, fill in and return a Capability
for Work questionnaire (ESA50) about how your disability, illness or health condition affects your ability to work. You may then be asked to go to
a face-to-face assessment with a Healthcare Professional.
Please note: The face-to-face assessment is not a medical examination. It is to help us understand how your disability, illness or health condition
affects your ability to work.
This means we can give you the right support to help you work when you can. This could include work you haven’t thought about before.
Not everyone is asked to go, but if you are given an appointment, it’s important you attend. If you don’t fill in and send back the questionnaire,
or go to your Work Capability Assessment if you are asked to, your ESA payments may be stopped.
We understand you might be nervous about your assessment. If you would like someone to go with you to the assessment please take them
with you. The person you take should know and understand you and your needs (for example, a relative, support worker or friend. They must be
16 or over).
You can find out more about the Work Capability Assessment and see a video of a face-to-face assessment by visiting the Health Assessment
Advisory Service website at chdauk.co.uk
After your assessment, we’ll decide how much your disability, illness or health condition limits your ability to work. We’ll make our decision using:
l the report written by the Healthcare Professional
l the answers from your questionnaire and
l any other medical evidence we get from your General Practitioner (GP) or Healthcare Professional who knows about your disability, illness or
health condition.
If we find you are capable of work, we will stop paying you ESA.
If we find your disability, illness or health condition limits your ability to work, you will be placed into one of two different groups. These are called
the work-related activity group and the support group.
If you can show you’re able to start doing things to prepare for work in the future, you will be put into the work-related activity group.
If your disability, illness or health condition severely limits your ability to work, you will be put into the support group.
We will pay ESA at an assessment rate until you’ve had your Work Capability Assessment. The amount of benefit we pay you once you’ve had
your Work Capability Assessment could change depending on which group you are placed in. If you’re placed in the work-related activity group
or support group we will backdate any arrears to week 14 of your claim.
Health and work conversation
You may get an appointment to go to a health and work conversation. The health and work conversation is a type of work focused interview.
This isn’t your Work Capability Assessment. The conversation isn’t about you looking or applying for work now, it’s about helping you get into
work when you’re able to in the future. It can help you get to know your work coach and plan simple steps to help build your confidence and
motivation. Your ESA payments may be reduced if you don’t go to and take part in your health and work conversation, and you don’t have a
good reason.
Notes for you to keep continued
Other help you might be able to get
Child Tax Credit
ESA does not include money for children or qualifying young people. But you can claim Child Tax Credits if you are responsible for a child or young person
under the age of 20. To claim tax credits you need to fill in a form available from HM Revenue & Customs (HMRC). You can contact them by ringing:
l Telephone: 0345 300 3900
l Textphone: 0345 300 3909
l Welsh: 0300 200 1900
To find out more about Child Tax Credit visit www.gov.uk/child-tax-credit
Housing Benefit and Council Tax reduction
Housing benefit can help to pay the rent for the place where you live. The amount you get depends on the amount of money you have coming in. For more
information on the amount you might get – contact your local council. Council Tax reduction is help to pay for your council tax. To apply, please contact your
local council. For more information on Housing Benefit and Council Tax reduction visit www.gov.uk
Support for Mortgage Interest Payments
We may be able to help towards your mortgage interest payments. This is normally paid directly to your lender. To find out more ask at your local jobcentre
or visit www.gov.uk/support-for-mortgage-interest/overview
Waiting days
Normally, you’ll not get any ESA for the first 7 days from when you want to claim. These are called waiting days. Not everyone has to serve waiting days. For
example, claimants who’ve been on ESA at any time in the previous 12 weeks.
Information you need to send us
If you’re getting Statutory Sick Pay, please send us your current Statement of Fitness for Work with your claim. Statements of Fitness for Work are also
known as fit notes, medical certificates, doctor’s statements or sick notes. If you can’t get Statutory Sick Pay, you don’t normally need to get a Statement of
Fitness for Work for the first 7 days of your disability, illness or health condition. We will need to see either a letter from your doctor or an original Statement
of Fitness for Work from the 8th day you want to claim ESA for.
Near the back of the claim form, we’ve listed all the other things we’ll need to see to help us make a decision on your claim. It’s important that you send
these to us if they apply to you. For example, your last payslips from work or your P45.
If you’re claiming for a partner
We may ask your partner to go for work focused interviews. If we need your partner to go for an interview, we’ll contact them after you’ve been getting
income-related ESA for 26 weeks or more. If they don’t take part in these interviews, it may affect your benefit.
If you’ve claimed Employment and Support Allowance before
If you’ve claimed ESA before and we decided during your last claim that you were able to do some type of work, we will ask you to provide evidence to show
that:
l you have a new disability, illness or health condition, or
l the effect your disability, illness or health condition now has on your ability to do some work has become alot worse since we last assessed you
We will try and contact you either by phone or in writing about your evidence.
How the Department for Work and Pensions collects and uses information
When we collect information about you, we may use it for any of our purposes. These include dealing with:
l benefits and allowances
l child benefit
l employment and training
l financial planning for retirement
l occupational and personal pension schemes
We may get information about you from others for any of our purposes if the law allows us to do so. We may also share information
with certain other organisations if the law allows us to. To find out more about how we use information, contact any of our offices or
visit our website atwww.gov.uk/dwp/personal-information-charter
Our service standards
At Jobcentre Plus we aim to provide a high standard of customer service at all times. Details of the standard of service you can
expect from us can be found at www.gov.uk
You can access our website from many libraries. For more information please contact Jobcentre Plus.
Equality and diversity
We are committed to treating people fairly, regardless of their disability, ethnicity, gender, sexual orientation, transgender status,
marital or civil partnership status, age, religion or beliefs. Please contact us if you have any concerns.
More information
To find out more about ESA visit www.gov.uk/employment-support-allowance
Notes for you to keep continued
Please read the notes at the front of this form. They will help you decide which type of ESA to claim.
Decide which type of ESA you want to claim.
Step 1
Step 2
Complete the right parts of the form for the type of ESA you’ve chosen.
For contribution-based ESA only fill in the answer boxes under You on page 1 to 25. Read the
notes on page 26 and then go to page 48 and fill in the rest of the form.
For income-related ESA fill in the answer boxes for You and Your partner on pages 1 to 25.
Read the notes on page 26 and then go to page 27 and fill in the rest of the form.
Step 3
Read, sign and date the Declaration.
Return this form and copies of any supporting information in the envelope provided.
If you do not claim income-related ESA now, but then ask for it at a later date,
we will normally only pay it from that later date.
How to fill in this form
Notes for you to keep continued
Please keep these notes but return the form to us.
Surname
First name and any other names
Any other surnames you have been known by
Title
National Insurance (NI) number
You can get this from payslips or from tax papers.
Or get in touch with Jobcentre Plus.
Letters Numbers Letter
Date of birth
Letters Numbers Letter
Part 1: About you and your partner
You Your partner
Address
Please tell us your address, and tell us your partner’s
address, if it is different.
Do you have a partner?
We use ‘partner’ to mean
l a person you live with who is your husband,
wife or civil partner, or
l a person you live with as if you are a
married couple.
Yes
No
Please answer all the questions that apply
to you.
Please answer all the questions that apply
to both you and your partner.
Does your partner agree to you making this claim?
No
We will get in touch with you about this.
But still tell us as much as you can about
your partner.
Yes Your partner may be required to take part
in a work focused interview if you are still
claiming for them in 26 weeks.
1
Please fill in this form in BLACK INK and in CAPITAL LETTERS
For our use:
Issue dateOffice code
/ /
ESA1 10/18
Title
Title
Mobile phone number
This is the number we’ll use to send you a text
if we need to.
Daytime phone number, if different.
Address, if different in the last 3 years
If you need to tell us about more than one other
address, use the space in Part 23 Other information.
Nationality
For example, British.
work home work home
You Your partner
Part 1: About you and your partner continued
If you are homeless, please tell us where
we can get in touch with you.
Email, if you have one.
2
ESA1 10/18
Part 1: About you and your partner continued
You Your partner
What is your marital or civil partnership status?
Tick all the boxes that apply. If you tick more
than one box, please tell us why in Part 23 Other
information.
Married or civil partner
Separated
Living together
Widowed or surviving civil partner
Single
Divorced or civil partnership dissolved
Date became widowed or surviving civil partner
Married or civil partner
Separated
Living together
Widowed or surviving civil partner
Single
Divorced or civil partnership dissolved
Date became widowed or surviving civil partner
Are you expecting a baby?
If you are expecting a baby or have a child under
four, you may qualify for Healthy Start vouchers and
vitamins. Call the Healthy Start helpline on 0845
607 6823 or visit www.healthystart.nhs.uk for an
application leaflet.
Yes
No
What date is the baby due?
Yes
No
What date is the baby due?
Have you had a baby in the 39 weeks before the
date you are claiming from?
Yes
No
What date was the baby born?
Yes
No
What date was the baby born?
3
ESA1 10/18
Part 2 About your claim
Do you get any special medical treatment?
By ‘special medical treatment’ we mean:
l dialysis
l radiotherapy
l chemotherapy
l plasmapheresis
l total parenteral nutrition for gross impairment
of enteric function.
Yes
No
Have any of your employers given you a
form SSP1?
You may be able to get Statutory Sick
Pay instead of Employment and Support
Allowance. Ask your employer about
Statutory Sick Pay before you fill in
this form.
You must send us a separate form SSP1
for each job you do along with this form.
Yes
No
Your employer will give you form SSP1 because
you cannot get Statutory Sick Pay, or because
your Statutory Sick Pay is coming to an end.
Statutory sick pay is money employers pay to
employees who are away from work for four
days or more in a row because of their health
condition, illness or disability.
4
What date do you want to claim Employment
and Support Allowance (ESA) from?
We will need more information from you if the
date you have written here is before the day you
called us. We will contact you about this.
Contribution-based ESA
Income-related ESA
Please tell us which type of ESA you’re claiming.
ESA1 10/18
Part 3 Special Rules
We have special rules for people who are
terminally ill (this means people who are not
expected to live longer than another six months).
If you qualify for special rules then you’ll get a
faster decision and the higher rate of ESA from
the date your claim was made. Please ask us if
you need help with applying under special rules.
Do you think that the special rules apply to you?
Yes
No
Ask your doctor or specialist for a DS1500 Report.
The DS1500 Report is a report about your medical condition. You will not have to pay for it.
You can ask the doctor’s receptionist, or nurse, or a social worker to arrange this for you. You do
not have to see the doctor. You should be given the DS1500 Report straight away. Ask for the
report in a sealed envelope if you do not want anyone to see it. Or you can ask your doctor or
specialist to send it to us for you.
If there is a delay in getting your DS1500 report, still send us your ESA claim form to prevent a
delay in your claim being processed. Then send us your DS1500 report as soon as you can.
Go to Part 4 About your disability, illness or health condition.
Have you already asked for a DS1500 Report
for your claim for Disability Living Allowance or
Personal Independence Payment?
Yes
No
You do not need to get another DS1500 Report. Send the DS1500 Report with your claim for
Disability Living Allowance or Personal Independence Payment.
Have you already sent the DS1500 Report with your
claim for Disability Living Allowance or Personal
Independence Payment?
Yes
No
5
ESA1 10/18
Please give brief details of your disability,
illness or health condition.
What date did your disability, illness or health
condition start?
Part 4: About your disability, illness or health condition
You Your partner
Address of the doctor who signs your
Statement of Fitness for Work.
Name of the doctor who signs your
Statement of Fitness for Work.
Phone number of the doctor who signs
your Statement of Fitness for Work.
Are you getting Statutory Sick Pay?
Yes
No
Please send us your current Statement
of Fitness for Work. We need to see the
original paper copy. We can’t accept
photocopies. Go to the next page.
Can you get Statutory Sick Pay?
If you are not sure, please ask your employer.
Yes
No
We’ll need to see either a letter from your
doctor or an original Statement of Fitness
for Work for any period you want to claim
ESA for.
6
ESA1 10/18
Have you been in hospital as an in-patient in the
last 52 weeks?
Date you went in to hospital
Part 4: About your disability, illness or health condition continued
You Your partner
Yes
No
Please tell us about this below.
Yes
No
Please tell us about this below.
Name and address of hospital
Have you come out of hospital?
Yes
No
Date you came out of hospital.
Yes
No
Date they came out of hospital.
Are you due to go into hospital in the next
3 months?
Yes
No
Date you are due to go into hospital.
Yes
No
Date they are due to go into hospital.
Are you, your partner, or any child or young
person living in your household registered
blind or severely sight impaired?
If anyone was registered blind or severely sight
impaired but has come off the blind register in
the last 28 weeks, please tell us about this in
Part 23 Other information.
Yes
No
Who is registered blind or severely sight
impaired?
What date did you, your partner or
anyone you are claiming for register as
blind or severely sight impaired?
Please tell us the name of the local
authority or council where this is
registered.
7
ESA1 10/18
Clock, payroll or employee number
Date the work started
Part 5: About work
You Your partner
Employer’s address
Employer’s name
Employer’s phone number
Job title
We need to know about work you are doing now.
Please tell us about any:
l work for an employer or self-employed work
l full-time or part-time work
l permanent or casual work
l unpaid work or paid work
l work as a company director
l time spent on Work-Based Training for Young People, and Skillseekers in Scotland.
Are you working at the moment?
Still tick Yes and answer the questions below if you’re
not working at the moment because of a disability,
illness or health condition, or you do voluntary work.
Yes
No
Please send us your P45.
Go to Part 6 About other benefits.
Please tell us about this below. If this
was paid work provide the last 5 weekly
payslips or last 2 monthly payslips.
Yes
No
Go to Part 6 About other benefits.
Please tell us about this below. If this
was paid work provide the last 5 weekly
payslips or last 2 monthly payslips.
If you are no longer working, date you last worked
Number of hours a week you usually work
hours hours
Number of days a week you usually work
days days
Number of hours a week you currently work
hours hours
Number of days a week you currently work
days days
Employer’s email if known
8
ESA1 10/18
Part 5: About work continued
You Your partner
Will your employer keep paying you if you
are off work because of a disability, illness or
health condition?
Yes
No
Yes
No
Do you get any money for expenses?
Yes
No
Yes
No
Does the employer pay any money towards
a pension for you?
Yes
No
Yes
No
Is the work you do voluntary work?
Yes
No
Yes
No
Can you choose whether or
not to be paid for the work?
Can they choose whether or
not to be paid for the work?
Yes
No
Yes
No
Do you get anything else in
return for working? For example,
things like accommodation
or food.
Do they get anything else in
return for working? For example,
things like accommodation
or food.
Yes
No
Yes
No
Are you self-employed or a sub-contractor?
Yes
No
Yes
No
We will send you a form B16
to fill in and return to us.
We will send you a form B16
to fill in and return to us.
Do you work in a specialist occupation?
By ‘specialist occupation’ we mean:
l an auxiliary coastguard
l a part-time fire-fighter
l a part-time member of a lifeboat crew, or
l territorial or reserve forces.
Yes
No
Yes
No
Are you involved in a trade dispute?
By ‘trade dispute’ we mean a dispute between you
and your employer or ex-employer.
Yes
No
Yes
No
We will write to you about this.
We will write to you about this.
9
ESA1 10/18
Part 5: About work continued
You
Do you know when you will be well enough to
work again?
Yes
No
Tell us when you will be well
enough to work.
Are you going to go back to work?
Yes
No
What date will you go back to work?
Did you work a night shift which included
midnight on the date you last worked?
Yes
No
Tell us about this below.
What date and time did you start the shift?
What date and time did you end the shift?
am / pm
am / pm
at
at
Will you go back to work on a night shift which
includes midnight?
Yes
No
Tell us about this below.
What date and time will you start the shift?
What date and time will you end the shift?
am / pm
am / pm
at
at
If you have more than one employer, please tell
us about them in Part 23 Other information.
Your partner
Yes
No
Tell us when you will be well
enough to work.
Yes
No
What date will you go back to work?
Yes
No
Tell us about this below.
am / pm
am / pm
at
at
Yes
No
Tell us about this below.
am / pm
am / pm
at
at
10
ESA1 10/18
Part 6: About other benefits
Please tell us about any benefits you are getting now, or have claimed in the past. We will tell you if they affect your ESA.
You must also tell us about any other benefits,
even if they are not on this list.
Do not tell us about:
l Housing Benefit
l a reduction in Council Tax
l Child Tax Credits
l Working Tax Credits.
We will ask you about these later on the form.
l Attendance Allowance
l Bereavement Allowance
l Bereavement Payment
l Carer’s Allowance
l Disability Living Allowance
l Incapacity Benefit
l Income Support
l Industrial Death Benefit
l Industrial Injuries Disablement Benefit
l Jobseeker’s Allowance
l Maternity Allowance
l Motability or any other help with
mobility problems
l Pension Credit
l Personal Independence Payment
l Reduced Earnings Allowance
l State Pension
l Severe Disablement Allowance
l Unemployability Supplement
l Universal Credit
l Widow’s Benefit
l Widowed Mother’s Allowance
l Widowed Parent’s Allowance
You Your partner
Are you getting or waiting to hear about
any benefits now?
Yes
No
Go to page 17.
Tell us about these benefits on page 12.
Yes
No
Go to page 17.
Tell us about these benefits on page 12.
11
ESA1 10/18
For example, you must tell us about
Name of the benefit
Who is getting the benefit?
Reference number
You can find this number on letters you’ve been sent
about the benefit.
How much is paid?
£
Part 6: About other benefits continued
Benefit 1 Benefit 2 Benefit 3
£ £
What day is it paid?
Fortnightly
Weekly
4 weekly
Monthly
Other
every
Fortnightly
Weekly
4 weekly
Monthly
Other
every
Fortnightly
Weekly
4 weekly
Monthly
Other
every
How often is it paid?
Other
Directly into a bank or
building society account
How is it paid?
Other
Directly into a bank or
building society account
Other
Directly into a bank or
building society account
Date of next payment
Is any money being deducted from the benefit?
Yes
No
Yes
No
Yes
No
How much is being deducted?
What is it being deducted for?
£ £ £
If you need to tell us about more than 3 benefits, please tell us in Part 23 Other information.
12
ESA1 10/18
Date of last claim or payment
Part 6: About other benefits continued
You Your partner
Address of the person being cared for
Name of the person being cared for
What is their name and address?
Have you ever claimed Carer’s Allowance?
Tick Yes, even if you were not paid any
Carer’s Allowance. This could have been
because you were better off getting
anotherbenefit.
Yes
No
Yes
No
Has the Carer’s Allowance stopped
in the last 3 months?
Yes
No
Yes
No
Does anyone care for you on a regular basis?
Yes
No
Yes
No
Do they get Carer’s Allowance for caring for you?
Tick Yes if they have claimed Carer’s Allowance and
are waiting to hear about it.
Yes
No
Yes
No
13
ESA1 10/18
Part 6: About other benefits continued
You Your partner Children or qualifying
young persons
Do you or your partner or any of your children
or qualifying young persons who live in your
household get Disability Living Allowance?
We use ‘child’ to mean a person aged 15 and
under who you are getting Child Benefit for.
We use ‘qualifying young person’ to mean
a person aged 16, 17, 18 or 19 who you are
getting Child Benefit for.
Yes
No
Yes
No
Yes
No
Is the Disability Living Allowance for
help with getting around?
Is the Disability Living Allowance for
help with personal care?
Yes
No
Yes
No
Yes
No
Higher rate
Lower rate
Higher rate
Lower rate
Higher rate
Lower rate
What rate is paid? What rate is paid? What rate is paid?
Yes
No
Yes
No
Yes
No
Middle rate
Lowest rate
Middle rate
Lowest rate
Middle rate
Highest rate Highest rate Highest rate
Lowest rate
What rate is paid? What rate is paid? What rate is paid?
Do you or your partner or any of the children
or qualifying young persons who live in your
household get:
l Attendance Allowance
l Motability
l War Pension Mobility Supplement, or
l other help with mobility problems?
Who gets the benefit?
Yes
No
Yes
No
Yes
No
Who gets the
benefit or help?
Do you, your partner or any of your qualifying
young persons who live in your household get
Personal Independence Payment?
Yes
No
Yes
No
Please tell us about
this below
Please tell us about
this below
Yes
No
Please tell us about
this below
If you get Disability Living Allowance for more than
one child or qualifying young person, tell us about it
in Part 23 Other information.
14
ESA1 10/18
Reference number
Part 6: About other benefits continued
You Your partner
Do you get War Widow’s or
War Widower’s Pension?
Yes
No
Yes
No
Is anyone getting, or has anyone just
stopped getting, Child Benefit for you?
Yes
No
Yes
No
Please tell us about them below:
Please tell us about them below:
Their surname
Their other names
Is it for help with mobility?
Is it for help with daily living?
You Your partner Children or qualifying
young persons
Yes
No
Enhanced rate
Standard rate
What rate is paid?
Yes
No
Enhanced rate
Standard rate
What rate is paid?
Yes
No
Enhanced rate
Standard rate
What rate is paid?
Yes
No
Standard rate
What rate is paid?
Yes
No
Standard rate
What rate is paid?
Yes
No
Standard rate
What rate is paid?
Enhanced rate
Enhanced rate
Enhanced rate
15
ESA1 10/18
Full previous name
Date of last payment
Part 6: About other benefits continued
You Your partner
Previous address
Have you claimed any other benefits in
the last 2 years?
If the claim was turned down, still tick Yes.
Yes
No
Yes
No
Name of benefit
Tell us about the last benefit
you claimed below.
Tell us about the last benefit
they claimed below.
Which benefit office dealt with the claim?
Was your name or address different when
you last claimed a benefit?
Yes
No
Yes
No
Please tell us about this below.
Please tell us about this below.
When did you move to your present address?
Is anyone getting extra money added
to their benefit for you?
Yes
No
Yes
No
Please tell us about this in
Part 23 Other information.
Please tell us about this in
Part 23 Other information.
Their address
Their Child Benefit number
Numbers Letters Numbers Letters
16
ESA1 10/18
Which countries did you go to, and when?
Part 7: About time spent abroad
You Your partner
What is their relationship to you?
For example, your father or mother.
Employed by a
foreign employer
Employed by a
UK employer
Have you:
l worked or claimed benefit outside the United
Kingdom in the last 5 years, or
l been a member, or in the family of a member of
HM Armed Forces outside the United Kingdom in
the last 12 weeks?
By the ‘United Kingdom’ we mean England, Scotland,
Wales and Northern Ireland.
Yes
No
Yes
No
Country 1
Country 1
From
From
To
To
Country 2
Country 2
From
From
To
To
Please tick the boxes that describe what you did
while you were abroad.
Claimed UK
benefit abroad
Self employed
Claimed foreign
benefit
Employed by a
foreign employer
Employed by a
UK employer
Claimed UK
benefit abroad
Self employed
Claimed foreign
benefit
Were you abroad because someone in
your family was in HM Armed Forces?
Yes
No
Yes
No
A member of HM
Armed Forces
A member of HM
Armed Forces
If you went to more than two countries, please
tell us about them in Part 23 Other information.
17
ESA1 10/18
Part 7: About time spent abroad continued
You Your partner
Are you exempt from paying UK income tax?
Yes
No
Yes
No
Were you abroad for more than one year in
total in the 5 years before you stopped paying
UK income tax?
For example, you were abroad one year for
6months and abroad for 7 months the year
before that.
Yes
No
Yes
No
18
ESA1 10/18
Name of the statutory payment
Who do you get your statutory payment from?
Part 8: About statutory payments
You Your partner
We need to know about any statutory payments you are getting from your employer, or have claimed in the past. We will tell you if they affect your ESA.
For example, you must tell us about:
l Statutory Adoption Pay
l Statutory Maternity Pay
l Statutory Paternity Pay
l Statutory Sick Pay.
These types of payments are required by law. They are paid by an employer to an employee if the employee satisfies the qualifying conditions.
Are you getting or waiting to hear about
any statutory payments now?
Yes
No
Yes
No
Please tell us about this below.
Please tell us about this below.
£ every
weeks/months
How much money do you get and how often?
What day is it paid?
£ every
weeks/months
Name of the statutory payment
Who did you get your statutory payment from?
Have you ever had a statutory payment
in the past?
Yes
No
Yes
No
Please tell us about this below.
Please tell us about this below.
£ every
weeks/months
How much money did you get and how often?
What day was it paid?
£ every
weeks/months
Go to Part 9 About pensions.
Go to Part 9 About pensions.
If you need to tell us about any other statutory
payments, tell us in Part 23 Other information.
19
ESA1 10/18
Part 9: About pensions
You Your partner
What type of pension are you
getting or waiting to get?
Are you getting or waiting to get a pension?
By ‘pension’ we mean:
l an occupational pension,
l a personal pension
l a retirement annuity contract, or
l payment from the Armed Forces Compensation
Scheme.
Do not tell us about State Pension here.
Tick Yes if you get:
l regular pension payments
l an annual compensation payment from a
previous job
l lump sum payments from an occupational or
personal pension. These could be paid yearly
l payments from the Pension Protection Fund
l Financial Assistance Scheme payments.
Go to Part 10 About permanent
health insurance.
Please tell us about this below.
If you have more than one
pension, please tell us about them in
Part 23 Other information.
Go to Part 10 About permanent
health insurance.
Please tell us about this below.
If your partner has more than one
pension, please tell us about them in
Part 23 Other information.
Yes
No
Yes
No
Please send us proof of your pension income. For example:
l a letter of entitlement from your employer or the insurance company that pays the pension
l a payment advice notice from your pension provider
l a current wage slip showing details of your pension income.
Send us the original documents. Do not send us photocopies. You do not need to send proof of a
payment from the Armed Forces Compensation Scheme.
If you do not send proof of pension income, you may lose benefit.
Personal pension
Retirement annuity contract
Occupational, work or employee’s pension
Public service pension
Pension paid to you as a beneficiary
Personal pension
Occupational, work or employee’s pension
Retirement annuity contract
An annuity is like an insurance policy. You use your
pension fund to buy a guaranteed income for life.
Public service pension
Pension paid to you as a beneficiary
An annuity is like an insurance policy. You use your
pension fund to buy a guaranteed income for life.
20
ESA1 10/18
Pension or policy reference number
When did the pension start, or when will it start?
Part 9: About pensions continued
You Your partner
Name and address of your pension provider
Their phone number
How much is the pension before any deductions?
For example, deductions like income tax.
£ for £ for
£ every
weeks/months/year
£ every
weeks/months/year
How much is the pension after any deductions?
£ every
weeks/months/year
£ every
weeks/months/year
How much are the deductions and what are they for?
£ for £ for
Date of first payment
Will the pension increase?
Yes
No
Yes
No
Date of first payment after the increase
Date of first payment after the increase
How much will your pension be after the increase?
£ every
weeks/months/year
£ every
weeks/months/year
Did you choose to take regular income from the
pension scheme instead of buying an annuity?
Yes
No
Yes
No
Was this the maximum income
you could take?
Was this the maximum income
they could take?
Yes
No
Yes
No
Did you inherit your pension?
Yes
No
Yes
No
ESA1 10/18
21
Part 10: About permanent health insurance
You Your partner
Name and address of the employer paying the
permanent health insurance premiums
Are you waiting to hear about any permanent
health insurance payment?
If Yes, let us know as soon as your permanent
health insurance payment has been awarded.
Yes
No
Yes
No
Do you get a permanent health insurance
payment?
If you have more than one permanent health
insurance payment, please tell us about them
in Part 23 Other information.
Yes
No
Go to Part 11 Education, training
and apprenticeship.
Yes
No
Go to Part 11 Education, training
and apprenticeship.
Their phone number
Has your contract of employment
ended with this employer?
Yes
No
Yes
No
When did it end?
When did it end?
Have you contributed more than half the
premiums towards any permanent health
insurance payment?
Yes
No
Yes
No
22
ESA1 10/18
Name of course, training scheme or apprenticeship
Part 11: Education, training and apprenticeship
You Your partner
Name and address of school, training centre,
college or university
Have you done a course of education, training or
apprenticeship in the last 4 years?
If you are still doing the course, tick Yes.
Yes
No
Yes
No
Please tell us about this below.
Please tell us about this below.
Go to Part 12 Where you live.
Go to Part 12 Where you live.
What was the course?
Education
Training
Apprenticeship
Education
Training
Apprenticeship
Number of hours a week
hours hours
Start date and official end date
to to
Do you have a final examination date?
Yes
No
Yes
No
What is this date?
What is this date?
Are you eligible for a student loan or grant?
Yes
No
Yes
No
Are you getting a student loan or grant?
Yes
No
Yes
No
What is the reference number?
What is the reference number?
Please tick all the boxes that apply
What period is the student loan or grant for?
to to
23
ESA1 10/18
Full name of the head of the household
Part 12: Where you live
You Your partner
Do you rent your home from a council?
Tick Yes:
l if the council is paying for you to stay in
bed and breakfast, or a hotel
l if you do not pay rent because you get
Housing Benefit.
Relationship to you
For example, parent, friend or relative
Do you live with parents, relatives or friends
as part of their family?
Yes
No
Yes
No
Do you share the rent or mortgage for the
place where you live with anyone else?
If you just share with your partner, tick No.
Yes
No
Names of the people you share with.
Yes
No
Names of the people they share with.
Yes
No
Name and address of the council.
Yes
No
Name and address of the council.
Do you pay a private landlord, landlady or housing
association for the place where you live?
Tick Yes if you:
l just pay for the place where you live
l pay for meals as well as the place where you live
l live in a hotel, guest house or hostel.
Yes
No
Please tell us their name and address.
Yes
No
Please tell us their name and address.
Tell us their name, title and relationship
to you below then go to page 26.
Title
Other title
Other title
Tell us their name, title and relationship
to you below then go to page 26.
24
ESA1 10/18
Part 12: Where you live continued
You Your partner
Do you pay any service charges for the place
where you live?
For example, cleaning and maintenance of stairs
and hallways.
Yes
No
Yes
No
How much do you pay and how often?
£ every
weeks/months/year
£ every
weeks/months/year
If you have any papers about the service charge,
please send them to us with this form.
Is the place where you live a Crown tenancy or
under a long term agreement?
By crown tenancy we mean where your landlord is
the crown or a government department.
By long term agreement we mean a tenancy
agreement which is for more than 21 years.
Yes
No
Are you already getting, waiting to hear about
or intending to claim Housing Benefit or apply
for a Council Tax reduction, or both?
Yes
No
Housing Benefit and Council Tax reduction do not
affect the amount of ESA you can get.
To claim Housing Benefit, fill in the form HCTB1. You can get form HCTB1 from your
local council or print it off from gov.uk then send the completed form HCTB1 to your
local council. For more information about Housing Benefit or if you wish to apply for a
reduction in your Council Tax please contact your Local Authority.
Did you claim Housing Benefit or apply for a
reduction in your Council Tax with a previous
claim for
l Jobseeker’s Allowance
l Income Support, or
l Employment and Support Allowance?
Yes
No
Yes
No
Did you get an extra 4 weeks
payment for your rent or council
tax reduction when you started
work after your previous claim?
Yes
No
Did they get an extra 4 weeks
payment for rent or council tax
reduction when they started
work after their previous claim?
Yes
No
25
ESA1 10/18
Part 13: What to do now
Make sure you have decided which type of Employment and Support Allowance (ESA)
you want to claim.
Please read the Notes again if you are not sure. These can be found at the front of this form.
Step 1
If you do not claim income-related ESA now, but then ask for it at a later date,
we will normally only pay it from that later date.
If you want to claim income-related ESA make sure you have completed the first part of the form
with your partner details (if you a partner). Then go to Part 14 Coming to the United Kingdom from
abroad and complete the rest of the form from there until the end.
If you want to claim contribution-based ESA go to Part 22 How we pay you and complete
the rest of the form from there until the end.
Step 2
Read, sign and date the Declaration.
Return this form and copies of any supporting information in the envelope provided.
Step 3
26
ESA1 10/18
Part 14: Coming to the United Kingdom from abroad
You Your partner
27
Everyone must answer these questions, if you do not your claim may be delayed.
By the United Kingdom (UK) we mean England, Scotland, Wales and Northern Ireland.
If a UK national, do you or your partner have the
right of abode in the UK?
For example, you have the right of abode in the UK
if you are a British citizen.
By the right of abode we mean you
l are free from immigration control, and
l do not need the permission of an immigration
officer to enter the UK, and
l can live and work in the UK without restriction.
Yes
No
Yes
No
At any time, have you or your partner come to
live or returned to live in the UK from abroad?
Yes
No
Please tell us about this below.
Please send passport or immigration
documents for the people you tell us about
below with this form. Or you can bring
the passport or documents to your local
Jobcentre Plus.
You can find the phone number and
address on the advert in the business
numbers section of the phone book. Look
under Jobcentre Plus.
eHRT completed? No Yes
Passport with UK visa / UK residence permit provided? No Yes
For our use
Please tell us about this below.
Please send passport or immigration
documents for the people you tell us about
below with this form. Or you can bring
the passport or documents to your local
Jobcentre Plus.
You can find the phone number and
address on the advert in the business
numbers section of the phone book. Look
under Jobcentre Plus.
Are you or your partner UK nationals?
By a UK national we mean someone from England,
Scotland, Wales or Northern Ireland.
Yes
No
Yes
No
ESA1 10/18
Part 14: Coming to the United Kingdom from abroad continued
What is your nationality?
Which country have you come from?
What date did you last come to the UK?
Was this to work in the UK?
Yes
No
Yes
No
Has the Home Office put a limit on
how long you can stay in the UK?
Yes
No
Yes
No
You
Your partner
Does your passport say no recourse to public funds?
Yes
No
Yes
No
If you have lived in the UK before,
when did you last leave the UK?
28
ESA1 10/18
Part 14: Coming to the United Kingdom from abroad continued
Have you or your partner come to the UK
under the Family Reunion Scheme?
Yes
No
Please go to the next page.
Please go to the next question.
Have you or your partner come to the UK under a
sponsorship undertaking?
A ‘sponsorship undertaking’ is a form that a relative
must sign to say that they will pay for your living
expenses if you settle in the UK. You can find out
more by visiting www.gov.uk/browse/citizenship
A sponsorship undertaking is not the same as the
Family Reunion Scheme.
Yes
No
Please tell us about this below.
Who is being sponsored?
Name of the sponsor
Address of the sponsor
Home Office reference number
What date did the sponsor sign the
sponsorship undertaking?
If more than one sponsor signed the
sponsorship undertaking, please tell us
about them in Part 23 Other information.
We may get in touch with you for more
information.
For our use
UK visa / UK residence permit / NASS35 provided? No Yes
29
ESA1 10/18
Part 14: Coming to the United Kingdom from abroad continued
You Your partner
30
Please answer all of these questions, even if you think they do not apply to you.
Are you or your partner an asylum seeker?
Yes
No
Yes
No
Did you or your partner first apply for asylum
before 3 April 2000?
Yes
No
Send us proof of the asylum application
with this form. Or you can bring the proof
to your local Jobcentre Plus.
If you are still an asylum seeker, you will
not usually be able to get benefit. But you
may get help from the Home Office.
Yes
No
Send us proof of the asylum application
with this form. Or you can bring the proof
to your local Jobcentre Plus.
If they are still an asylum seeker, they will
not usually be able to get benefit. But they
may get help from the Home Office.
Have you or your partner recently had a
successful decision on your asylum application?
Yes
No
Yes
No
Send us proof of the decision with this form.
Or you can bring the proof to your local
Jobcentre Plus.
Send us proof of the decision with this form.
Or you can bring the proof to your local
Jobcentre Plus.
What was the date when you got the successful
decision of your asylum application?
Have you or your partner been supported by the
Home Office while waiting for a decision on your
asylum application?
Yes
No
Send us details of any support given to you
by the Home Office. For example, a letter
from the Home Office which tells us about
these things.
Yes
No
Send us details of any support given to
them by the Home Office. For example,
a letter from the Home Office which tells
us about these things.
ESA1 10/18
Part 15: About children and qualifying young persons
Do you have any children or qualifying young
persons living permanently in your household who
are dependent on you?
Do not include:
l foster children
l children or qualifying young persons who are
boarded out with you while they wait to be adopted.
Yes
No
Please tell us about these children or qualifying young persons below.
l We use ‘child’ to mean a person aged 15 or under who you are getting
Child Benefit for.
l We use ‘qualifying young person’ to mean a person aged 16, 17, 18 or 19
who you are getting Child Benefit for.
Go to Part 16 About bank and building society accounts, savings and property.
Children or qualifying young persons living permanently in
your household who are dependent on you
Are you
getting or have
you claimed
Child Benefit
for this child
or qualifying
young person?
Relationship
to you
Relationship
to your partner
Does the child
or qualifying
young person
have a parent
or parents
who live
somewhere
else?
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
Surname Other names Date of birth
Male or
female
For example, son, daughter, niece,
grandson, stepdaughter or none.
M F
Tell us in Part 23 Other information
l if you have more than 8 children or qualifying young persons
l if you have any children or qualifying young persons who normally
live with you but are in boarding school or local authority care.
If you have told us about a child or qualifying young person
who has a parent who lives somewhere else, ask for
leaflet DWP007 about child maintenance options if you are
claiming benefits. You can get it from Jobcentre Plus.
31
ESA1 10/18
Part 16: About bank and building society accounts, savings and property
You
We need to know about savings that you or your partner have.
By ’savings’ we mean all money, savings, investments and property in the United Kingdom (UK) or abroad
which belong to you or your partner. By the ‘UK’ we mean England, Scotland, Wales and Northern Ireland.
Do you or your partner have any of the following?
Please tick No or Yes for every item in the list.
Tell us about accounts even if they are not in credit.
No Yes Amount
£
Bank accounts, including current accounts
£
Building society accounts, including current accounts
£
Post Office® accounts
£
National Savings & Investments accounts
£
£
National Savings Certificates
£
£
Premium bonds
Number of units Issue number
Purchase price
£
Income Bonds or Capital Bonds
Number of units
Name
Purchase price
Number of units
Your partner
No Yes Amount
£
£
£
£
£
£
£
£
Number of units Issue number
Purchase price
£
Number of units
Name
Purchase price
Number of units
32
ESA1 10/18
No Yes Amount
No Yes Amount
No Yes Amount
No Yes Amount
£
Unit Trusts
£
ISAs, PEPs and other investments
£
Government Stock
£
Money or property held in trust
£
Cash
£
A lump sum personal injury payment in last 52 weeks
£
Insurance for repairs or possessions
£
Money from the sale of a home
Date you got the payment
£
Money set aside for essential repairs
£
Outstanding money from the Social Fund
£
Other money from benefits owed to you
£
World War II compensation payment
£
Far Eastern Prisoners of War compensation payment
£
State Pension lump sum
You
Do you or your partner have any of the following?
Please tick No or Yes for every item in the list.
Tell us about accounts even if they are not in credit.
No Yes Amount
£
£
£
£
£
£
£
£
Date you got the payment
£
£
£
£
£
£
Your partner
No Yes Amount
Part 16: About bank and building society accounts, savings and property continued
33
ESA1 10/18
Part 16: About bank and building society accounts, savings and property continued
You
Do you or your partner have any of the following?
Please tick No or Yes for every item in the list.
Tell us about accounts even if they are not in credit.
No Yes Amount
£
Money from a trust fund
Do not tell us about
payments from:
l The Macfarlane Trust
l The Eileen Trust
l The Skipton Fund
l The Fund
l MFET Ltd
l The Caxton Foundation.
£
Any other money
£
How much are the savings worth in total?
Add together all the amounts from pages 32, 33
and 34 to work this out.
Do you and your partner’s savings add up to
£5,500 or more?
Yes
No
Please send us proof of your savings with this form. For example, a recent
bank statement or a savings book updated within the last month.
Have your savings been more than £5,500 during
the last 6 months?
Yes
No
Please send us proof of your savings with this form. For example, a recent
bank statement or a savings book updated within the last 6 months.
Your partner
No Yes Amount
£
£
£
Shares
If you or your partner have more than 3 types of
shares, tell us about them in Part 23.
Number of units Name of company
£
£
You Your partner
34
ESA1 10/18
No Yes
Part 16: About bank and building society accounts, savings and property continued
Apart from the home you live in, do you or your
partner own or jointly own any other property or
land in the UK or abroad?
Tick Yes if the property or land is:
l on a mortgage or loan, or
l jointly owned.
Yes
No
What is it?
Property
Land
What is the address of the property or land?
What is the property or land currently used for?
What was the original purpose for buying it?
Who does this property or land belong to?
Is the property or land up for sale?
Yes
No
Have you or your partner sold any property other
than where you lived during the last 6 months?
Yes
No
Please send us proof of the sale of this
property or land.
35
ESA1 10/18
Part 17: About other money coming in
For example, you must tell us about:
l fostering fees or allowances
l prison discharge grant
l any training allowance
l Guardian’s Allowance
l Child Benefit
l Child Tax Credit
l Working Tax Credit
l student grants or loans
l money from a mortgage protection policy
l money from a charity or benevolent fund
l any other money coming in.
We need to know if you or your partner have any other money coming in.
l War Pension
l War Widow’s, or Widower’s, Pension
l payments from the Pension Protection Fund
l Financial Assistance Scheme payments
l sick pay from an employer
l benefits, allowances and pensions not from
social security
Do you, your partner or anyone else you are
claiming ESA for, have any other money coming in?
Yes
No
Please tell us about this below.
Money 1
Money 2
Who gets this money?
Where does the money come from?
£ every
weeks/months
How much money do they get, and how often?
£ every
weeks/months
What day is it paid?
You must send us proof of any other money coming in, for example:
l a statement from the person or company that pays the money
l a court order
l payslips, or
l a full bank statement showing the amount and how often it is paid.
You do not need to provide proof of Child Benefit, Tax Credits or a student loan
or grant. We may ask you about student loans and grants at a later date.
If you need to tell us more about any other money coming in, please tell us in Part 23 Other information.
36
ESA1 10/18
Part 17: About other money coming in continued
Does anyone owe any money to you, your partner
or anyone else you are claiming ESA for?
This might be for things like
l arrears of maintenance, or
l money lent to someone.
Yes
No
Please tell us about this below.
Money 1
Money 2
Who is owed this money?
How much money are they owed?
What is this money for?
When do you expect the money to be paid?
£ £
Do you, your partner or anyone else you are
claiming ESA for, get maintenance payments?
Tell us about maintenance paid:
l voluntarily
l because of a written agreement
l because of a court order, or
l because of a child maintenance assessment.
Yes
No
Please tell us about this below.
Money 1
Money 2
Who gets this money?
Who is this money for?
Who is paying you this money?
£ every
weeks/months
How much money do you get, and how often?
£ every
weeks/months
What day is it paid?
If you need to tell us about more payments, please
tell us about them in Part 23 Other information.
If you need to tell us about more payments, please
tell us about them in Part 23 Other information.
37
ESA1 10/18
Part 17: About other money coming in continued
Do you or your partner get any payments
from a credit insurance policy?
Yes
No
Please tell us about this below.
What items, if any, were bought using the credit
that you had?
Which of these items are covered by the
insurance policy?
Who does the insurance company
make the payments to?
To you or your partner.
Direct to the supplier.
To the credit company.
£ every
weeks/months
How much is paid, and how often?
When did the payments start?
When will the payments end?
If you need to tell us more about any other money
coming in, please tell us in Part 23 Other information.
A credit insurance policy covers credit or loan
repayments if you are unemployed or sick
You must send us details of what the insurance company has paid you.
38
ESA1 10/18
Part 17: About other money coming in continued
Does anyone pay you, your partner,
oranyone else you are claiming ESA for,
to rent rooms or property?
For example, boarders, lodgers, tenants
and subtenants.
Yes
No
Please tell us about this below.
Rent 1
Rent 2
Who pays the rent?
Who do they pay?
£ every
weeks/months/year
How much do they pay, and how often?
£ every
weeks/months/year
What day is it paid?
Tick here if the money they pay includes
any money for heating or meals.
Meals
Heating
Meals
Heating
If you need to tell us about more payments, please
tell us about them in Part 23 Other information.
Do you or your partner hold any bank accounts,
investments or property, in this country or abroad,
which belong to someone else?
Yes
No
Are these bank accounts, investments or
property in your or your partner’s name?
Your partner
You
Please tell us about them in
Part 23 Other information.
39
ESA1 10/18
Part 18: About other people who live with you
We need to know about any other people who live in the same household as you.
We need this information to make sure we work out your housing costs correctly.
Do not tell us about:
l members of your immediate family, if you live with them in their household
l people who just share a hall or bathroom or toilet with you, or who live in a
separate flat or bedsit in the same house
l other residents, if you live in a care home
l foster children, or children or qualifying young persons boarded out with you
while they wait to be adopted.
Please tell us about:
l relatives, if they live in your household
l friends
l anyone else who lives in your household.
Do any other people live in your household who
you have not already told us about?
If you need to tell us about more than 4 people,
please tell us in Part 23 Other information.
Yes
No
Please tell us about these people below.
Person 1
Person 2
Go to Part 19 Owning your home.
Full name
Title
Other title
Other title
Date of birth
Relationship to you
Do they work for 16 hours or more a week?
Yes
No
Yes
No
Other title
Person 3
Person 4
Full name
Title
Other title
Date of birth
Relationship to you
Do they work for 16 hours or more a week?
Yes
No
Yes
No
40
ESA1 10/18
Title
Title
Title
Title
Part 18: About other people who live with you continued
Person 1
Person 2
Tell us about:
l earnings
l benefits
l any other money they have coming in.
If they have earnings, tell us the amount before tax,
National Insurance and any other money has been
taken off.
We need to know if any of the people living with
you have any money coming in.
You do not have to answer these questions. But if
they do not have much money coming in, you may
get more ESA.
Do not tell us about:
l The Macfarlane Trust
l The Eileen Trust
l The Skipton Fund
l The Fund
l MFET Ltd
l The Caxton Foundation.
Do they have any money coming in?
Yes
No
Yes
No
Where does the money come from?
This could be wages, a pension or benefits.
£ every
weeks/months/year
How much is coming in, and how often?
£ every
weeks/months/year
Does this person usually live with you?
Yes
No
Yes
No
If No, where do they usually live?
What date did you start sharing accommodation?
Why did you start to share accommodation?
How long do you expect this to continue?
Why do you think this is?
Has the person shared accommodation with you
in the past?
Yes
No
Yes
No
41
ESA1 10/18
Part 18: About other people who live with you continued
Person 3
Person 4
Do they have any money coming in?
Yes
No
Yes
No
Where does the money come from?
This could be wages, a pension or benefits.
£ every
weeks/months/year
How much is coming in, and how often?
£ every
weeks/months/year
Does this person usually live with you?
Yes
No
Yes
No
If No, where do they usually live?
Are any of these people you have told us about:
l married to each other or living together as if
they are married, or
l civil partners?
We call these people ‘partners’.
Yes
No
Please tell us about them.
is the partner of
is the partner of
If you need to tell us about more than 4 people,
please tell us in Part 23 Other information.
What date did you start sharing accommodation?
Why did you start to share accommodation?
How long do you expect this to continue?
Why do you think this is?
Has the person shared accommodation with you in
the past?
Yes
No
Yes
No
42
ESA1 10/18
Part 19: Owning your home
Do you or your partner own your own home?
If the home is on a mortgage or loan, or if it is
leasehold or freehold, tick Yes.
Yes
No
Go to Part 20 Living in a care home.
You may be eligible for a reduction in your Council Tax. Contact your local council or visit www.
gov.uk for more information on how to apply. This will not affect the amount of Employment
and Support Allowance you get.
Do you or your partner have an insurance policy
to pay the mortgage or home loan if you become
unemployed or ill?
Yes
No
Have you made a claim on the
insurance policy?
Yes
No
Is any part of the place where you live
rated as a business?
Yes
No
Do you or your partner pay ground rent?
By ground rent we mean a regular payment
of rent paid to the freeholder.
Please send us proof of your ground rent.
For example, your lease.
Yes
No
How much is paid, and how often?
£ every
weeks/months/year
Is your or your partner’s home leasehold?
By leasehold we mean a property you own
for a fixed amount of time but not the land
on which it stands.
Yes
No
When the lease was first granted,
was it for more than 21 years?
Yes
No
43
Do you or your partner have a mortgage or
loan on your home?
Yes
No
ESA1 10/18
Part 20: Living in a care home
Do you or your partner live in a care home?
Yes
No
Go to Part 21 Your circumstances.
You Your partner
Yes
No
Go to Part 21 Your circumstances.
Are you or your partner paying for
this care out of your savings?
Yes
No
Yes
No
Are you or your partner living in
a care home temporarily?
Yes
No
Yes
No
How long do you expect to stay?
How long do they expect to stay?
Are your friends or family paying for this care?
Yes
No
Did you or your partner get help from
the Health Authority, Health Trust, or the
Local Authority Social Work Department
(Scotland) to get a place in the home?
Yes
No
Don’t know
Yes
No
Don’t know
When did you move to the address where
you live now?
When did you move to the address where
you live now?
Do your and your partner’s savings add
up to £10,000 or more?
Yes
No
Please send us proof of your savings
with this form. For example, a recent
bank statement or a savings book updated
within the last month.
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ESA1 10/18
Did you or your partner ever own your home
before you moved to where you live now?
Yes
No
Go to Part 21 Your circumstances.
Yes
No
Go to Part 21 Your circumstances.
Who owned the home?
Your partner
You
Both of you
Has it been sold?
Yes
No
When was it sold?
£
How much was it sold for?
If it has not been sold, does anyone live there?
Yes
No
We will write to you about this.
Part 20: Living in a care home continued
45
ESA1 10/18
Surname
Other names
National Insurance (NI) number, if you know it
Letters Numbers Letter
Date of birth
Letters Numbers Letter
Part 21: Your circumstances
You Your partner
46
Address
Have you separated from a person who used to be
your partner in the last 6 months?
If you need to tell us about more than one
person, please tell us about them in Part 23
Other information.
Yes
No
Please tell us about this below.
Go to part 22 How we pay you.
Yes
No
Please tell us about this below.
Go to part 22 How we pay you.
When did you separate?
Is this separation temporary?
Yes
No
Yes
No
Please tell us about this below.
For example, the reason for the separation
and how long you expect it to last.
Please tell us about this below.
For example, the reason for the separation
and how long you expect it to last.
Has this person gone abroad?
Yes
No
Yes
No
Have they gone abroad
permanently?
Have they gone abroad
permanently?
Yes
No
Yes
No
ESA1 10/18
Part 21: Your circumstances continued
47
Will the person who used to be your partner keep
paying anything towards the rent or mortgage,
or any household bills?
Yes
No
Please tell us about this below.
Payment 1 Payment 2 Payment 3 Payment 4
£ £ £ £
When will you get this payment?
How often will this be paid?
How much do you expect to get?
What is this payment for?
If you need to tell us about more payments, please
tell us about them in Part 23 Other information.
If the person who used to be your partner
is still paying towards your mortgage,
who do they make payments to?
Direct to your lender
Direct to you
Has the person who used to be your partner
stopped paying you money?
Yes
No
Please tell us about the last payment you received.
£
When was this paid?
How much did you get?
What was this payment for?
ESA1 10/18
Part 22: How we pay you
We normally pay your money into an account
Many banks and building societies will let you collect your money at the post office.
We will tell you when we will make the first payment and how much it will be for.
We will tell you if the amount we pay into the account is going to change.
Finding out how much we have paid into the account
You can check your payments on account statements. The statements may show
your National Insurance (NI) number next to any payments we have made. If you
think a payment is wrong, get in touch with the office that pays you straight away.
If we pay you too much money
Sometimes we might pay you too much money. We call this an overpayment. An
overpayment can result for a number of reasons for example, there was a change
in your circumstances and we didn’t know about it. The law says we can take back
any money we shouldn’t have paid you.
We will contact you before we take back any money.
What to do now
l Tell us about the account you want to use on the next page. By giving us your
account details you
– agree that we will pay you into an account, and
– understand what we have told you above in the section If we pay you
too much money.
l If you are going to open an account, please tell us your account details as soon
as you get them.
l If you do not have an account or cannot open an account, please contact us on
0800 169 0310 and we will give you more information.
48
ESA1 10/18
Part 22: How we pay you continued
About the account you want to use
l You can use an account in your name, or a joint account.
l You can use someone else’s account if
– the terms and conditions of their account allow this, and
– they agree to let you use their account, and
– you are sure they will use your money in the way you tell them.
l You can use a credit union account. You must tell us the credit union’s
account details. Your credit union will be able to help you with this.
l If you are an appointee or a legal representative acting on behalf of the
claimant, the account should be in your name only.
Please tell us your account details below.
It is very important you fill in all the boxes correctly, including the
building society roll or reference number, if you have one. If you tell us
the wrong account details your payment may be delayed or you may
lose money.
You can find the account details on your chequebook or bank statements.
If you do not know the account details, ask the bank or building society.
Name of the account holder
Please write the name of the account holder exactly
as it is shown on the chequebook or statement.
Full name of bank or building society
Sort code
Please tell us all 6 numbers, for example: 123456.
Account number
Most account numbers are 8 numbers long. If
your account number has fewer than 10 numbers,
please fill in the numbers from the left.
Building society roll or reference number
If you are using a building society account you
may need to tell us a roll or reference number.
This may be made up of letters and numbers,
and may be up to 18 characters long. If you are
not sure if the account has a roll or reference
number, ask the building society.
You may get other benefits and entitlements we do
not pay into an account. If you want us to pay them
into the account above, please tick this box.
49
ESA1 10/18
Part 23: Other information
Please use this space to tell us anything else
you think we might need to know.
If there is not enough space, please use a separate
sheet of paper. Make sure that you:
l tell us who the information is about, and
l put your full name and National Insurance
number on each sheet of paper, and
l sign and date each sheet that you use.
Don’t tell us about your disability, illness or health
condition here. We will send you a questionnaire
about this later.
50
ESA1 10/18
Surname
Other names
Any other surnames you have been known by
Title
Other title
National Insurance (NI) number
You can get this from payslips or from tax papers.
Letters Numbers Letter
Date of birth
Part 24: Filling in this form for someone else
Address
Mobile phone number
Daytime phone number, if different
work
home
Are you filling in this form for someone else?
Yes
No
Go to Part 25 Declaration.
Tell us about yourself below.
mobile
51
ESA1 10/18
Title
Part 24: Filling in this form for someone else continued
Are you signing this form for someone else?
Yes
No
Go to Part 25 Declaration.
Even though you can fill in this form for another adult,
they must still sign it themselves unless one or more
of the following apply.
Tick one of the boxes below.
I am signing this form on their behalf because
I have Power of Attorney for them.
I am a receiver or deputy for them under a Court
of Protection Order, or in Scotland a tutor, curator
or guardian appointed in terms of the law.
They cannot manage their own affairs because of
a disability, illness or health condition.
They can’t sign for themselves because of their
disability, illness or health condition.
The Department for Work and Pensions has
already appointed me to get their benefits and
to deal with letters about their benefits.
If the person does not know you are signing
this form for them, please tell us why.
Please send us your power of attorney document or certified copy
with this claim form. Remember to sign the Declaration at Part 25.
Please send us the relevant document or certified copy with
this claim form. Remember to sign the Declaration at Part 25.
We will get in touch with you about this. The Department for Work and Pensions
may appoint you to get their benefits and to deal with letters about their benefits.
We will get in touch with you about this.
We will send all letters about this claim directly to you.
52
ESA1 10/18
Signature
Part 25: Declaration
Please read the Notes at the front of this form, and the text below.
Then sign and date the form at the bottom of this page.
l I declare that I have read and understand the notes at the front of this form, the
information I have given on this form is correct and complete and I have included
all my income and savings.
l I understand that I must report all changes in my circumstances which may
affect my entitlement promptly and by failing to do so I may be liable to
prosecution or face a financial penalty. I will phone 0800 169 0310, or write to
the office that pays my benefit, to report any change in my circumstances.
l If I give false or incomplete information or fail to report changes in my
circumstances promptly, I understand that my Employment and Support
Allowance may be stopped or reduced and any overpayment may be recovered.
In addition, Imay be prosecuted or face a financial penalty.
l I agree that
– the Department for Work and Pensions
– any approved health care professional advising the Department
– any organisation with which the Department has a contract for the provision of
assessment services
may ask any of the people or organisations mentioned on this form for any
information which is needed to deal with
– this claim for benefit
– any request for this claim to be looked at again
and that the information may be given to that approved health care professional
or organisation or to the Department.
l I also understand that the Department may use the information which it has
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 or be awarded in the future.
l I agree to my doctor, or any doctor treating me, being informed about the
Secretary of State’s determination on
– limited capability for work
– limited capability for work related activity, or
– both.
This is my claim for Employment and Support Allowance.
Date
Please tick this box if someone filled in this
form for you.
53
ESA1 10/18
Part 26: What to do now
Claim form
Proof of identity
It is important that we can be sure of your identity when you claim ESA. We
may need to ask you more questions about this. We may also need to see
official documents that help prove your identity.
A National Insurance number is not proof of identity.
Even if you do not have all the documents and account details we ask for, send this form back to us straight away. Send us the documents and account
details you do not have later.
You may lose benefit if you do not provide original documents within one month of the date that your claim form was sent to you.
Check
Check
Check
You
Your partner
This ESA claim form.
About you and your partner
Any passport or immigration
documents we have asked for.
Any proof we have asked for
about an asylum application or
asylum decision.
4
4
About money
You
Your partner
Proof of savings over £5,500
including any share certificates.
About work, education or
training
Proof of savings over £10,000, if you
or your partner live in a care home.
Proof of any pension income
you have told us about.
Proof of any payments from
a credit insurance policy.
Any proof we have asked for
about any other money coming in.
About a disability. illness or
health condition
You
Your partner
Statement of Fitness for Work.
Form SSP1.
DS1500 Report.
The last 5 weekly payslips or
last 2 monthly payslips, if you or
your partner are still working.
Form P45.
Discharge papers if you have
just left HM Forces.
Details of Home Office support.
UK visa or UK residence permit.
NASS35.
Proof of sale of property or land.
Proof of service charges on
property.
that you have answered all the questions on this form that apply
to you and your partner, if you have one.
that you have signed and dated this form.
that you have sent us all the documents we have asked for.
Use the checklist below.
54
ESA1 10/18
Part 27: Where to send your completed form and documents
Declaration
Send this form and any documents we have asked for in the enclosed envelope.
Part 28: What happens next
l If we can pay you ESA we will write to tell you how your benefit has been worked out and how you will be paid.
l If we can’t pay you ESA we will write to tell you why and what to do if you disagree with the decision.
l If we can pay you, we will start to pay you the basic rate of ESA into the account you have told us about.
l We’ll write and tell you when the Work Capability questionnaire is being sent to you. This questionnaire will be about
your disability, illness or health condition. Please look out for this in the post.
l We will not be able to deal with your claim and may have to send your claim form back to you if
– you have not answered all the questions on this form that apply to you and your partner, if you have one, or
– you have not provided all the documents we have asked for.
We will write to you and tell you about all the documents we still need to see to help us make a decision on your claim.
This is important as your claim could close if you don’t send them to us.
For our use
The answers I have given to the questions
on this form have been read back to me.
I agree they are correct and complete as far
as I know and believe.
Claimant’s signature
Date
Interviewing officer’s signature
Interviewing officer’s name
55
ESA1 10/18
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