Fill - Free fillable Help using this PDF claim form (Cabinet Office) PDF form

Help using this PDF claim form

You can save data typed into this PDF form if you use Adobe Reader XI or a newer version.

This means that you do not have to fill in the form in one session.

This form will only save if:

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•

opened in Adobe Reader XI or a newer version.

The form will not save in:

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•

other pdf readers, for example Preview on a Mac or Foxit on a PC.

You can download Adobe Reader free of charge from the Adobe website.

If you are having technical difficulties:

• downloading the form

• navigating around the form, or

• printing the form

Please contact the DWP Online helpdesk.

Phone: 0345 604 3349

Minicom (textphone): 0345 604 0523

Calls to 0345 numbers cost no more than a standard geographic call and count towards

any free or inclusive minutes in your landline or mobile phone contract.

Note

: Calling UK non-geographic numbers from abroad can incur a significant charge.

Please check with your telephone service provider.

Email: dwponline.helpdesk@

dwp.gsi.gov.uk

Opening hours

Monday to Friday: 8.00am - 6.00pm

Closed on all Public and Bank Holidays.

For help and 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.

International Pension Centre

The Pension Service 11

Mail Handling Site A

Wolverhampton

WV98 1LW

United Kingdom

International Pensions

Direct Payment

Notes to help you fill in Part 9 of IPC BR1 GOV

What is International Pensions Direct Payment?

International Pensions Direct Payment is the Department for Work and Pensions’ way of paying your pension or benefit direct to an account of your choice

outside the United Kingdom.

The advantages

Getting your money paid in this way has many advantages:

•

it is secure

•

it is convenient

•

you will benefit from competitive exchange rates based on bulk buying of currency

•

there are no postal delays

•

there are no cheque clearance delays

•

it is less expensive for us to arrange, which saves taxpayers’ money.

How does it work?

The £ sterling value of your money will be converted to local currency and paid directly to your account. Your pension or benefit will be paid in arrears.

You can choose to be paid at the end of 4 or 13 weeks

If you choose to be paid every 4 weeks

The money will be paid into an account for you in the week following each 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 weeks

The money will be paid into an account for you in the week following each 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.

But if you are only going to get a small State Pension or benefit you will be paid once a year.

IPC BR1 GOV Banking Notes 12/13

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You can work out what exchange rate has been used for each payment by dividing the amount by the £ sterling value of your money.

About the account you want to use

•

You can use an account in your name, or a joint account.

•

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.

•

If you are an appointee or a legal representative acting on behalf of the customer, the account should be in your name only.

Finding out how much we have paid into the account

We will tell you when we will make the first payment and how much it will be for in £ sterling. You can check your payments on account statements. The

statements may show your National Insurance number next to any payments we have made. If you think a payment is wrong, get in touch with us

straight away.

Changes in pension or benefit

We will tell you when the money you get from us goes up. The amount of money we send you may change because of currency exchange rates.

If we pay you too much money

If we pay you too much money we have the right to take back any money we pay that you are not entitled to. This may be because of the way the

payment system works. For example, you may give us some information which means you are entitled to less money. Sometimes we may not be able to

change the amount we have already paid you. This means we will have paid you money that you are not entitled to. We will contact you before we take

back any money.

Important additional information

You must tell us straight away when your bank or account details change. If you do not, your payments may be delayed.

If you require further information, please contact us on +44 191 218 7777.

You may find it useful to keep these notes.

Notes to help you fill in Part 9 of IPC BR1 GOV - continued

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State Pension claim form

IPC BR1 GOV 12/13

Part 1 About you

Benefit you can get because of this claim can be paid more quickly if you:

•

answer all the questions on the form that apply to you, and your husband, wife or civil partner if you have one

•

send us all the documents we ask for with this form.

If you cannot do this, get in touch with us, but benefit you can get because of this claim may be delayed.

Surname or family name

All other names, in full

Title

All other surnames or family names you have been

known by or are using now Please include maiden name

all former married names and all changes of family nam

Your permanent address

Phone number Add your national and local area code

What is this number? Please tick

Yes

Please tell us your National Insurance (NI) Number

You can find your NI number on your NI number card,

letters from social security or payslips. But do not delay

sending in this form if you cannot find the number.

If you do not know your NI number, have you ever

had one or used one at any time?

Letters Numbers

Letter

Home Work Mobile Fax

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Part 1 About you - continued

Nature of evidence

For official use only

Verified by

Checked by

Certificate returned by

Date of birth

Please send us your birth certificate

We need the original certificate. If you do not wish to send your original certificate a photocopy may be

acceptable but only if the photocopy has been stamped and signed by any of the following

a civil servant

or a doctor or surgeon registered under the laws of the country where the declaration is made

or a minister of religion

or a barrister, solicitor or advocate authorised to practice in the country where the declaration is made

or a notary public or any person allowed to administer oaths in the country where the declaration is made

or an officer of a bank authorised to sign documents on the customer’s behalf

or a magistrate

If you do not have your birth certificate, and are unable to send it quickly, do not delay sending in this claim

form.

You must remember to send us all the documents we ask for. If you do not, benefit you can get because

of this claim may be delayed.

Other documents on which your date of birth is recorded may be acceptable.

Are you sending your birth certificate with this form?

Yes

We will send the certificate back to you

as soon as we can.

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Part 1 About you - continued

Have you ever lived or worked in the

United Kingdom or the Isle of Man?

Please go to Part 2.

Please tell us about this below.

Yes

Have you, your husband, wife or civil partner

ever claimed any of the following benefits in

or from the United Kingdom or the Isle of

Man? The United Kingdom is England,

Scotland, Wales and Northern Ireland.

•

State Pension

•

Graduated Retirement Benefit

•

Widow's Benefit

•

Bereavement Benefit

Which benefit was claimed?

Who claimed the benefit?

If you are a married woman getting

State Pension you need only fill in

Parts 2, 4, 8 and 11 of this form.

Yes

Please tell us about this below.

You Your husband, wife or civil partner

Please tell us any address(es) you had in

the United Kingdom or the Isle of Man and

the dates that you lived there. If you need

more space use the space in Part 10 at the

end of this form.

Address

Dates

From

If you need more space use the

space in Part 10 at the end of this

form.

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Part 1 About you - continued

Please tell us about any time you spent in

the United Kingdom or the Isle of Man.

Include any holidays. If you need more

space use the space in Part 10 at the end

of this form.

From To

Have you ever been in HM Forces?

Please tell us

the date you enlisted

the date you were discharged

where you were discharged

the Regiment or corps you were in

your service number

your rank

Which service were you in?

Army Navy

RAF

Yes

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Part 1 About you - continued

Did you work for an employer in the

United Kingdom or the Isle of Man?

Employer’s name and address

If you know the wages are dealt

with at a different address, please

give us that address, including

the postcode.

The date you started work for

this employer

The date you stopped work for

this employer if you have stopped

working for them

Payroll, staff or other

reference number

Yes

Please tell us about any employers you have had. If you have

had more than 2 employers, tell us about them in Part 10.

Employer 1 Employer 2

Please go to Part 2.

Do you have any contribution or insurance

record cards or notices that show you were

employed in the United Kingdom?

Yes

Please send us the original documents,

not photocopies.

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Part 2

About your husband, wife or civil partner

For official use only

Husband's status before

marriage

Details of wife immediately

before marriage (status)

Details of wife immediately

before marriage (Surname)

Details of wife immediately

before marriage

eg. maiden name

Yes

What is your current marital or

civil partnership status?

If married more than once give details

of previous marriages in Part 10

Single Please go to Part 4

Married or civil partner

Divorced or civil partnership dissolved

Widowed or surviving civil partner

Marriage or civil partnership annulled

Separated

Tell us about your husband, wife or civil partner

Their surname or family name

Their other names

Any other names by which they have

been known

Their National Insurance (NI) number if

you know it

If you do not know their NI number did

they ever work or live in the United Kingdom?

Their address, if different from yours

Their date of birth

Date of marriage or civil partnership formation

Date of divorce, annulment or

civil partnership dissolution

The date they died, if you are widowed or a

surviving civil partner

Letters Numbers

Letter

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Part 2

About your husband, wife or civil partner - continued

Certificate returned by

Nature of evidence

Verified by

Checked by

Certificate returned by

Nature of evidence

Verified by

Checked by

Certificate returned by

Nature of evidence

Verified by

Checked by

For official use only

1. If you are married or a civil partner please send us

your marriage certificate or civil partnership

certificate.

2. If you are widowed or a surviving civil partner please

send us your late husband’s, late wife’s or

late civil partner’s death certificate and your

marriage certificate or civil partnership certificate.

If you are getting United Kingdom Widow’s Benefit or

Bereavement Benefit there is no need to send these

certificates as we already have these details.

3. If you are divorced or a person whose civil

partnership has been dissolved please send us your

decree absolute or confirmation of dissolution of civil

partnership and your marriage certificate or civil

partnership certificate. In Scotland a decree absolute is

called a decree of divorce.

4. If your marriage or civil partnership was annulled

please send us the certificate of annulment and your

marriage certificate or civil partnership certificate.

Are you sending your marriage or

civil partnership certificate with this form?

Yes

We will send the certificate back as soon as

we can. Please fill in the rest of this form.

You need not fill in Part 3.

Are you sending your decree absolute, decree of divorce,

certificate of annulment or confirmation of dissolution

of civil partnership with this form?

Yes

We will send the certificate back as soon as

we can. Please fill in the rest of this form.

You need not fill in Part 3.

Are you sending your late husband’s, late wife’s or

late civil partner’s death certificate with this form?

Yes

We will send the certificate back as soon as

we can. Please fill in the rest of this form.

You need not fill in Part 3.

You must remember to send us all the documents we ask for. If you do not, benefit you can get because of this claim

may be delayed. Other documents on which dates are recorded may be acceptable.

If you do not wish to send your original certificates photocopies may be acceptable - please see the notes on page 2

of this form.

Please fill in the rest of this form including Part 3

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If you do not have the necessary birth, marriage,

divorce, annulment or death certificate and the

event took place in

Great Britain

Northern Ireland

The Isle of Man

The Channel Islands

Ireland

or a civil partnership certificate or confirmation

of dissolution of civil partnership and the event

took place in

Great Britain

Northern Ireland

please give the appropriate information below.

Part 3

Evidence of dates of birth, marriage, formation of civil partnership, divorce,

dissolution of civil partnership, annulment or death

Details of your birth

Address where you were born

Father’s full name

Mother’s full name

Mother’s name before marriage

With this information we can look for proof of the

event from official records. This could take some

time and may delay a decision on your claim.

If you do not have the necessary certificate and

the event took place in a country which is not

listed opposite we will not be able to look for

proof from official records. Please try to get a

certificate or some other proof of the event and

send it to us as soon as you can.

You must remember to send us all the documents

we ask for.

If you do not, benefit you can get because of this

claim may be delayed.

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Part 3

Evidence of dates of birth, marriage, formation of civil partnership, divorce,

dissolution of civil partnership, annulment or death - continued

Details of marriage or civil partnership

Address where you were married or

formed a civil partnership

Maiden name of wife

Any other surnames of wife or civil partner

Full name of wife’s or civil partner’s father

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Address where you were married or formed

a civil partnership

Address where you were divorced, your

marriage was annulled or your

civil partnership was dissolved

Full name of petitioner

Address of the place of death

Where and when was the death registered

Date

Part 3

Evidence of dates of birth, marriage, formation of civil partnership, divorce,

dissolution of civil partnership, annulment or death - continued

Details of divorce, annulment or dissolution of civil partnership

Details of death of your late husband, wife or civil partner

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Part 4 When to claim State Pension

If you are a man – your 65th birthday

If you put off getting your State Pension after you are 65, you

may get extra State Pension or a lump sum when you do get your

State Pension.

If you are a woman – your State Pension age

If you are claiming State Pension on your husband’s NI contributions,

you cannot be entitled from a date earlier than his 65th birthday.

If you are getting Widow's/Bereavement Benefit your payday will

stay as it is.

If you put off getting your State Pension from the date you reach

State Pension age, you may get extra State Pension or a lump sum

when you do get your State Pension.

Notes

– We can accept your claim if it is received no earlier than 4 months

before the date you wish to get State Pension, or the date you reach

State Pension age whichever is the later.

– If you put off claiming your State Pension from the date you are

entitled, you can get extra State Pension or a one-off taxable lump

sum payment. You can find out more about putting off claiming your

State Pension and the effect on increases for adults who depend on

you in leaflet Deferring your State Pension.

– The minimum period you must put off claiming your State Pension to

get extra State Pension is 5 weeks or 12 months to get a lump sum

payment. Extra State Pension or lump sum payments are worked out

over the time you put off claiming your State Pension.

– Your State Pension cannot be backdated more than 12 months before

the date your claim is received. If you backdate your claim this will

affect any extra State Pension or lump sum payment you could get.

(If you have already submitted a valid claim to a country which has a

social security agreement with the United Kingdom, or a country that

applies the European Union rules on social security, it may be

possible to accept an earlier date of claim for United Kingdom

State Pension purposes).

– You can find out more about State Pension in leaflet State pensions -

Your guide. You can access the leaflet on the internet at

www.gov.uk/state-pension or request by phone on

+44 191 21 87777.

You will normally get your money from the State Pension payday on or after the date you claim from. This payday is a fixed day of the week

when you get your money for that week.

Any money that you earn will not affect your State Pension.

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Part 4 When to claim your State Pension - continued

Part 5 About National Insurance (NI) contributions

If you are a married woman or a widow

Have you been self-employed in the

United Kingdom or the Isle of Man at

any time since 6 April 1978?

Have you been paying reduced rate

NI contributions?

Yes

What date do you want to claim your

State Pension from?

If no date is input this may delay payment

of your State Pension

Insert the date

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Part 5 About National Insurance (NI) contributions - continued

Did you pay these contributions through an

employer?

Employer’s name and address

If you know the wages are dealt

with at a different address,

please give us that address,

including the postcode.

Staff payroll or other reference

number

If you do not know it, tell us the

job or department.

Date you started work for this

employer

Date you stopped work, if

appropriate

Yes

Please tell us about any United Kingdom or Isle of Man employers you

have had while you were outside the United Kingdom or Isle of Man. If

you have had more than 2 employers, tell us about the others in Part 10.

Employer 1 Employer 2

Have you been employed in the

United Kingdom or the Isle of Man

or have you worked for a United Kingdom

or Isle of Man employer and paid

NI contributions as an employee in

the last 2 years before reaching

State Pension age?

Please go to Part 6.

Yes

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Your husband, wife or civil partner

Part 6 About other benefits or entitlements

Are you, your husband, wife or civil partner

getting any of these benefits or entitlements

from the United Kingdom or the Isle of Man?

Or have you received any of these benefits or

entitlements since you reached State Pension

age?

Tick Yes if you, your husband, wife or

civil partner are waiting to hear about

a benefit.

•

Attendance Allowance

•

Bereavement Benefit

•

Carer’s Allowance

•

Child Benefit

•

Disability Living Allowance

•

Employment and Support Allowance

•

Graduated Retirement Benefit

•

Guardian’s Allowance

•

Incapacity Benefit

•

Income Support

•

Industrial Death Benefit

•

Jobseeker’s Allowance

•

Pension Credit

•

Reduced Earnings Allowance

•

Severe Disablement Allowance

•

State Pension

•

Temporary Allowance for Widows

•

Unemployability Supplement

paid because of

- a war disability due to service with

HM forces

or - an industrial accident or disease.

•

War Widow’s or Widower’s Pension

•

Widow’s Benefit

•

Working Tax Credit

Yes

Please tell us about the benefits or entitlements.

We need to know if you, your husband, wife or civil partner are getting any benefits or entitlements from the Department for Work and Pensions

or any other United Kingdom government department, as they will normally affect your basic State Pension. It will usually be reduced by the

amount of the other benefit.

You

Benefit 1

Name of benefit or entitlement

Who is getting this or waiting to hear

about this?

Reference number, if known

This is on letters about the benefit

or entitlement.

Benefit 2

Name of benefit or entitlement

Who is getting this or waiting to hear

about this?

Reference number, if known

This is on letters about the benefit

or entitlement.

Benefit 3

Name of benefit

Who is getting this or waiting to hear

about this?

Reference number, if known

This is on letters about the benefit

or entitlement.

If you, your husband, wife or civil partner

get more than 3 benefits or entitlements,

tell us about them in Part 10.

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Which benefit or entitlement are they

getting increased?

What is the reference number of the

benefit or entitlement?

This is on letters about the benefit or entitlement.

Part 6 About other benefits or entitlement - continued

Are you, your husband, wife or civil partner

getting any social security benefits from

•

another country

•

State Social Security Authority

•

waiting to hear about a claim for a

benefit?

We only want to know about benefits

paid by a State Social Security Authority

Yes

Please tell us about the benefits. If you need more space

use the space in Part 10 at the end of this form.

Name of benefit

Who is getting this or waiting to

hear about this?

Reference number, if known

This is on letters about the benefit.

Name and address of

State Social Security Authority

Yes

one

getting

incr

eas

their social

security benefit or entitlement for you?

Yes

ve you been in receipt of United Kingdom

Child Benefit at any time since 1978?

You o Y ur husband, wife or civil partner

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Part 7 Living or working outside the United Kingdom

You do not need to tell us about any time

that you were overseas with HM Forces.

Please tell us about any time that you

have lived in -

•

a country outside the United Kingdom

•

the Channel Islands

•

Ireland

If you do not give us this information now

you may suffer loss of/or delay in getting

your United Kingdom pension. This may

also apply to any foreign pension to which

you may be entitled.

Country you lived or worked in

When you lived or worked there

Did you pay into the social

security scheme of that

country?

Name and address of

Social Security Authority

Yes

What was your social security

reference number?

Yes

What was your social security

reference number?

We need to know about the time that

you have lived or worked outside the

United Kingdom. This is because if you

paid into the social security system in

another country, it may count towards

your State Pension. We may need to

forward details of your United Kingdom

claim to them and exchange information

with them about the contributions made

and any entitlement that you may have

under their scheme.

From

Please tell us about the time you have lived or worked outside the United Kingdom. If you have lived or worked in more than 2 countries,

tell us about them in Part 10

Country 1 Country 2

What is your nationality?

Lived

Worked

Lived

Worked

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Part 8 Time in hospital

Yes

Please tell us the name and address

of the hospital, the date you went

into hospital and the date you left

hospital.

Have you been in a hospital

•

in the United Kingdom or Isle of Man

•

Leopardstown Park Hospital, Dublin

•

whilst in British Forces Posted Overseas

since you reached State Pension age, or

the date you want to start receiving your

State Pension from?

Name of hospital

Address and postcode of hospital

Hospital phone number

Ward name or number

Date you went into hospital

Date you came out of hospital

Code Number

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Part 9 How we pay you

It is very important that you give us all the information that is needed to make a payment into your account. If you tell us the

wrong account details your payment may be delayed or you may lose money. If any of the information we ask for below and on

page 19 is not part of your account details then do not fill those boxes in. You should check with your bank that the details you give

us are correct.

Please tell us:

your bank or financial institution’s full name

your bank or financial institution’s full address

name of the account holder fill in from the left

Please continue on page 19

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Part 9 How we pay you - continued

Please tell us:

account number fill in from the left

account type should be: 0 for checking account

1 for savings account

3 for other account

bank/branch code fill in from the left

International Bank Account Number (IBAN) fill in from the left

Bank Identification Code (BIC) fill in from the left

If your code has only 8 characters, put XXX at the end to make 11 characters

If you have a cheque book for your account please attach a paying-in slip to this form. This will help us to confirm your details.

I would like to be paid at the end of every 4 weeks 13 weeks

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Part 10 Other information

Use this space to tell us anything else you think we might need to know.

You can continue on a separate piece of paper if you need to. If you continue on a separate piece of paper, make sure you

•

write your full name, address and NI number on it

•

sign and date it

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Part 11 Declaration

I understand that I must promptly tell The Pension Service, by phone or

in writing, of anything that may affect my entitlement to, or the amount

of, my State Pension.

I declare that the information I have given on this form is correct and

complete as far as I know and believe.

I understand that if I knowingly give false information, I may be liable to

prosecution or other action.

I understand that if I fail to promptly notify the Department of a change

in circumstances, I may be liable to prosecution or other action.

This is my claim for State Pension

Signature

Date

1. Check that you have answered all the

questions on this form that apply to you.

2. Check that you are sending us all the

documents we have asked for.

These could be your birth certificate, your

marriage certificate, your civil partnership

certificate, your decree absolute or

decree of divorce, your dissolution of civil

partnership document, certificate of

annulment or death certificate.

3. Check that you have signed this form.

4. When to claim - If you want to claim your

State Pension now, please send this form

to us without delay.

You can get your State Pension paid more

quickly if you:-

- answer all the questions on the form that

apply to you, and your husband, wife or

civil partner if you have one

- send us all the documents we ask for.

If you cannot do this, please get in touch

with us, but your State Pension may be

delayed or you could see a loss of your

State Pension.

5. Send this form and any documents to:

International Pension Centre

The Pension Service 11

Mail Handling Site A

Wolverhampton

WV98 1LW

United Kingdom

Part 12 What to do now

When you return your claim form

We will make enquiries for you so that we can consider your

claim for pension or benefit. This can take around 8 weeks

from the date we get your claim.

About your claim

It would help if you did not phone us to check on the progress

we are making unless you want to report a change that would

affect your claim - for example, bank details etc.

We will only acknowledge your claim if you are sending a

•

birth certificate

•

marriage certificate

•

civil partnership certificate

•

certificate of annulment

•

certificate of civil partnership dissolution

•

decree absolute

•

decree of divorce

•

death certificate

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Please sign the form here after printing

Part 13 What happens next

Part 14 How we collect and use information

When we collect information about you we may use it for any

of our purposes. These include dealing with:

•

social security benefits and allowances

•

child support

•

employment and training

•

financial planning for retirement

•

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.

find out more about how we use information, visit our

website at www.gov.uk/dwp/personal-information-charter

or contact any of our offices.

We will write and tell you how much State Pension you can get and when it will be paid from.

If you are not entitled to a State Pension we will tell you why.

IPCBR1GOV_122013 interactive v0.0:IPCBR0001.qxd 11/03/2015 12:29 Page 24

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