Fillable Maternity Allowance Claim Form Interactive Version (Cabinet Office)

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Maternity Allowance Claim Form Interactive Version (Cabinet Office)

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The Maternity Allowance Claim Form Interactive Version (Cabinet Office) form is 35 pages long and contains:

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Help using this PDF claim form
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If you are having technical difficulties:
• downloading the form
• navigating around the form, or
• printing the form
please contact the DWP Online helpdesk.
Phone: 0800 169 0154
Minicom (textphone): 0800 169 0254
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.
DO NOT RETURN THIS PAGE WITH YOUR MA1 CLAIM FORM
MA1 05/18
Maternity
Allowance
MA1 05/18
Your claim for Maternity Allowance
Claim Maternity Allowance if you are expecting a baby and you
are or have been:
• employed but cannot get Statutory Maternity Pay, or
• self-employed, or
• not employed or self-employed, but you take part in the
business of your self-employed spouse or civil partner, or
• an agency worker.
Use this form to claim Maternity Allowance if you live in
England, Scotland or Wales
If you live in Northern Ireland, get a claim form from
www.nidirect.gov.uk/maternity-allowance
To fill in this form, you will need to read the Notes sheet and
Test Period table that came in this claim pack. Please fill in this
form with BLACK INK and in CAPITALS.
Your benefit payments may be delayed if you do not
l answer all the questions on this form that apply to you
l send us all the documents we ask for.
If you cannot do this, get in touch with us straight away.
If you have any problems filling in the claim form,
someone else can do it for you.
Please sign the form yourself if you can. If another person signs
it for you, your claim may be delayed.
If you want any more information about Maternity Allowance,
get in touch with the Maternity Allowance office which deals
with your benefit, you can find their address and contact details
in Part 13 of this form.
For information about benefits and services visit
www.gov.uk/browse/benefits
If you claim more than 3 months after the date your
Maternity Allowance is due to start, you will lose money.
Save
Part 1: About you
2
Surname
Other names
Any other surnames you have been
known by
If you need to tell us about more
names, use the space in Part 11
Other information.
National Insurance (NI) number
You can find this on your National
Insurance (NI) numbercard, letters
from the Department for Work and
Pensions or payslips.
Letter
Address
Code
Mobile phone number
Home phone number
privatepersonal
If you do not know your NI number,
have you ever had one or used one
at any time?
Yes
No
Email address
where we can contact you
Please confirm if this email address is
secure
Postcode
Date of birth
Address, if different in the
last 3 years
If you need to tell us about more
than one address, use the space in
Part 11 Other information.
MA1 05/18
What date do you expect to have
your baby?
You must send in your MATB1
certificate.
If your baby has already been born,
please tell us the date you had
your baby.
Please see page 6 of the
Notes sheet for evidence of birth.
If your baby was stillborn, please see
page 6 and page 8 of the
Notes sheet.
Numbers
Letters
Number
Title
Save
Part 2: About your work
3
Yes
No
Yes
No
a Look at the Test Period table
that came in this claim pack.
Find the week in column 1 that
includes the date you expect to
have your baby. Read across to
column 4 to find the start of the
15th week before the week your
baby is due. Write the date from
column 4 here.
b Were you employed by an
employer during this 15th week?
We explain what we mean by
employer and employed on
page 3 of the Notes sheet.
Please go to question c below.
Please go to Part 3 About your Test Period.
c If you were employed in this 15th
week you may be able to get
Statutory Maternity Pay (SMP).
Please get in touch with your
employer and ask about SMP.
Will you be able to get SMP?
If you cannot get SMP, each of your employers must give you a form SMP1 to send to us.
You must send us an SMP1 from your employer if you were employed up to and
including the 15th week before the week your baby is due, even if you are no longer
employed by them. If you do not send us an SMP1, your claim will be delayed.
Please tell us why:
MA1 05/18
You cannot claim Maternity Allowance. See page 2 of the
Notes sheet.
Save
Part 3: About your Test Period
4
c employed?
a Look under column 1 of the
Test Period table that came in
this claim pack to find the week
that includes the date you
expect to have your baby.
Write that week here.
b Look across the table to column 2
to find the first day of your Test
Period.
Write that date here
Look across the table to column 3
to find the last day of your Test
Period.
Write that date here
Date, month and year
For example:
DD/MM/YYYY
Yes
No
Go to Part 4 About employment and earnings in your
Test Period. See page 9 of the Notes sheet.
d self-employed?
No
Yes
Go to Part 6 About self-employment in your Test Period.
See page 10 of the Notes sheet.
e taking part in activities
related to the business of
your self-employed spouse
or civil partner?
No
Yes
Go to Part 7 About taking part in activities related to the
business of your self-employed spouse or civil partner
during your Test Period. See page 11 of the Notes sheet.
If more than one of the above
applies to you in your Test
Period, please complete each
relevant part in full.
During your Test Period, are you or
have you been:
MA1 05/18
Your Test Period is the 66 weeks
up to and including the week
before the week your baby is
due. See page 5 of the Notes
sheet.
No
Yes
f During your Test Period, are
you or have you been an
agency worker?
Go to Part 5 Agency workers
Save
Part 4: About employment and earnings in your Test Period
5
Employer 1 Employer 2
Postcode
a Please tell us about ALL your employers in your Test Period.
If you do not tell us about ALL your employers your claim will be delayed. Use the space in Part 11
of this form to give us any further information. For example, if your employer was an agency, if you
had more than two employers or if you still have a contract with your employer.
Name and address of
the employer
Date your employment started
Date your employment stopped
If you still have a contract with
your employer, do not fill this
date in.
Payroll, employee, clock or
works number
Phone number
b How often are you
normally paid?
Fortnightly Monthly
If other,
how often?
Weekly 4-weekly
Fortnightly Monthly
If other,
how often?
Weekly 4-weekly
MA1 05/18
We need you to choose 13 weeks worth of payslips from within your Test Period that you worked out
in section b of Part 3, so we can work out how much Maternity Allowance you can get.
Please see page 9 of the Notes sheet and enclose the payslips for those 13 weeks.
c What date did you last work?
Only fill this date in if you have
stopped work to have your baby.
Save
6
Part 4: About employment and earnings in your Test Period continued
d Did you get any sick pay after
you last worked?
Yes
No
Yes
No
MA1 05/18
If No, what was your sickness reason?
e If you have not yet started your
maternity leave, on what date
will it start?
f What date would you like your
maternity allowance to start?
You may not be able to choose your maternity allowance period if
you have been off sick for pregnancy-related reasons during or
after the 4th week before the week your baby is due.
If Yes, what dates did you get sick pay?
from
to
Was your sickness pregnancy-related?
Save
Part 5: Agency workers
Yes
No
a Do you or have you worked for
an agency within your test
period?
Agency 1
Postcode
b Name and address of Agency 1?
c Phone number
d What dates did you work
within your test period?
(The dates you worked out at
Part 3b, page 4).
From To
From To
Go to Part 6 About self-employment in your Test Period.
From To
From To
From To
From To
From To
From To
Fr
om To
From To
From To
From To
7
MA1 05/18
From To
From To
From To
From To
Agency 2
Postcode
f Phone number
g What dates did you work
within your test period?
(The dates you worked out at
Part 3b, page 4).
e Name and address of Agency 2?
Save
i Did you get any sick pay after
you last worked?
Yes
No
Was your sickness pregnancy-related?
Yes
No
If No, what was your sickness reason?
j Have you stopped work to have
your baby?
Yes
No
Go to question k on this page.
What date do you plan to stop work to have your baby?
k What date did you stop work to
have your baby?
l What date would you like your
maternity allowance to start?
h What date did you last work?
Part 5: Agency workers continued
8
MA1 05/18
You may not be able to choose your maternity allowance period if
you have been off sick for pregnancy-related reasons during or
after the 4th week before the week your baby is due.
from
to
If Yes, what dates did you get sick pay?
Save
Part 6: About self-employment in your Test Period
9
c Have you stopped work to
have your baby?
d What date did you stop work to
have your baby?
e What date do you want us to pay
your Maternity Allowance from?
See page 7 and 8 of the Notes
sheet.
To find out more about self-employment and registration with
HM Revenue & Customs, see page 10 of the Notes sheet.
a What date were you registered
as self-employed?
MA1 05/18
Yes
No
Go to question d on this page.
From
If No, what date did your self-employment end?
b Are you still self-employed?
Yes
No
If you have not paid enough Class 2 National Insurance
contributions during your Test Period to entitle you to the
standard rate of MA, we will contact HMRC who will offer you
the opportunity to pay these contributions.
What date do you plan to stop work to have your baby?
Save
Part 7: About taking part in activities related to the business
of your self-employed spouse or civil partner during
your Test Period
10
To find out more about taking part in activities related to the business of your self-employed spouse or
civil partner see page 11 of the Notes sheet.
On what date did you start to take
part in activities related to the
business of your self-employed
spouse or civil partner?
Yes
No
Did you stop taking part in activities related to
the business of your self-employed spouse or
civil partner due to
l your pregnancy?
l sickness?
l pregnancy-related sickness?
If you have not stopped yet,
on what date do you plan to stop
taking part in activities related to
the business of your self-employed
spouse or civil partner?
What duties or activities did you or
do you perform to support the
business of your self-employed
spouse or civil partner?
We may ask for more information
about the duties or activities you do.
Tell us when in your Test Period
you took part in activities related
to the business of your self-
employed spouse or civil partner.
Yes
No
Yes
No
Yes
No
Have you stopped taking part in
ac
tivities related to the business
of your self-employed spouse or
civil partner?
What date did you stop?
Go to the next question.
MA1 05/18
From To
From To
From To
From To
From To
From To
From To
Save
11
Part 7: About taking part in activities related to the business
of your self-employed spouse or civil partner during
your Test Period
continued
About your self-employed spouse or civil partner
Your spouse’s or civil partner’s
National Insurance (NI) number
Your spouse’s or civil partner’s
other names
Address
if it is different from your address.
If you do not know their address,
write Not known.
Your spouse’s or civil partner’s
surname
Letters Numbers Letter
Postcode
About your marriage or civil partnership
What was the date of your
marriage or civil partnership?
If you converted or changed your
civil partnership into a marriage or
married your civil partner, enter
the date your marriage is treated
as starting on.
In which country did your marriage
or civil partnership take place?
Yes
No
Has your marriage ended in
div
orce or has your civil
partnership been dissolved?
On what date?
MA1 05/18
About the self-employment of your spouse or civil partner
When did your spouse or civil
partner become self-employed?
Yes
No
Is your spouse or civil partner
registered as self-employed with
HM Revenue & Customs?
What is their registration number or
Unique Tax Reference number?
Your claim may be delayed if we do
not have your original marriage or
civil partnership certificate.
Title
Save
12
About the self-employment of your spouse or civil partner continued
If your spouse or civil partner is no
longer registered as self-employed,
when did they end their self-
employment registration with
HM Revenue & Customs?
What is or was the full name
and address of the business of
your self-employed spouse or
civil partner?
Postcode
Yes
No
Does your self-employed spouse
or civil partner have a business
website?
What is the web address?
What is the nature of the
business of your self-employed
spouse or civil partner?
Tell us what is or was produced
or sold, or what services are or
were delivered.
We may ask you for more
information about the business
of your self-employed spouse or
civil partner.
Part 7: About taking part in activities related to the business
of your self-employed spouse or civil partner during
your Test Period
continued
MA1 05/18
We may need to contact your spouse or civil partner about paying Class 2 National Insurance (NI)
contributions. If your spouse or civil partner has not paid enough Class 2 NI contributions to entitle
you to Maternity Allowance, and you do not consent to us contacting them to explain how they can
make the payments, we may not be able to pay you Maternity Allowance.
If you do not wish us to contact
your spouse or civil partner
about your claim for Maternity
Allowance, please tick here.
Save
13
Part 8: About periods abroad in your Test Period
Yes
No
See page 12 of the Notes sheet.
Go to Part 9 About other benefits.
Did you spend any time abroad,
other than holidays, in your
Test Period?
During these visits, were you
l employed abroad by an
overseas employer
l employed abroad by a
UK employer
l self-employed abroad
l taking part from abroad in
activities related to the UK
business of your self-employed
spouse or civil partner
l a member of a service
family abroad
l receiving any benefits in a
foreign country
l none of these?
Tick the boxes which apply to you.
Which countries did you spend
time in?
From
to
Country
Country
What periods did you pay National
Insurance contributions for?
From to
From to
MA1 05/18
From
to
If you need to tell us about more than 2 countries,
please use the space in Part 11 Other information
Save
14
Employer 1 Employer 2
Postcode
Name and address of the employer
Please give details of your employers while you were abroad.
If you need to tell us about more than two employers, please use the space in Part 11 Other information.
Part 8: About periods abroad in your Test Period continued
Date your employment started
Date your employment stopped
If you still have a contract with your
employer, do not fill this date in.
Payroll, employee, clock or
works number
Phone number
How often are you normally paid?
Fortnightly Monthly
If other,
how often?
Weekly 4-weekly
Fortnightly Monthly
If other,
how often?
Weekly 4-w
eekly
MA1 05/18
Save
15
Part 9: About other benefits
Are you getting any of these
benefits or entitlements?
Tick Yes if you are waiting to hear
about a benefit.
Even if the benefit or entitlement is
not listed here, tell us about it
anyway. We will contact you if we
need more information.
For example:
l Bereavement benefits
l Carer’s Allowance
l Child Benefit
l Employment and Support
Allowance
l Incapacity Benefit
l Income Support
l In Work Credit or Return to Work
Credit
l Jobseeker’s Allowance
l Pension Credit
l State Pension
l Statutory Adoption Pay (SAP)
l Statutory Maternity Pay (SMP)
l Statutory Sick Pay (SSP)
l Training Allowance
l War Widow’s Pension
l Widow’s Benefit
l Universal Credit
l any other benefits.
If you need to tell us about more
than 6 benefits, please use the
space in Part 11 Other information.
Yes
No
Please tell us about the benefits.
Name of benefit Reference number, if known.
We need to know about any money that you are getting from the Department for Work and Pensions,
any other government department or the Training Agency.
We also need to know about any money that your spouse, civil partner or anyone else is either
l getting for you, or
l getting added to their benefit for you.
This money may make a difference to your Maternity Allowance. Your Maternity Allowance can also
make a difference to the other money that you can get. There is more information about this in
NI17A A guide to Maternity Benefits. You can find the guide on our website. The address is
www.gov.uk/browse/benefits
MA1 05/18
Save
16
Part 10: 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
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.
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, please contact us and we will give you
more information.
Fill in the rest of this form. You do not have to wait until you have opened an
account or contacted us.
MA1 05/18
Save
17
Part 10: How we pay you continued
Sort code
Please tell us all 6 numbers,
for example 12-34-56.
Full name of bank or
building society
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.
Name of the account holder
Please write the name of the account
holder exactly as it is shown on the
chequebook or statement.
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 the box.
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.
How often do you want us to
pay your benefit?
Every 4 weeks
Every 2 weeks
MA1 05/18
Save
18
Part 11: Other information
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 you put
your full name and National Insurance (NI) number on each sheet of paper, and sign
and date each sheet that you use.
MA1 05/18
Save
19
The table below tells you which documents you need to send in with your claim.
Please tick the boxes below to show what you are sending to us.
Everyone
You must send the original, not a
photocopy of a Maternity Certificate MAT
B1. See page 6 of the Notes sheet.
If you are claiming after the baby is born
You must also send your baby’s birth
certificate if the date you had your baby is
not on the MAT B1. See page 6 of the Notes
sheet.
If you were employed by an employer
in the 15th week before the week your
baby is due and you cannot get Statutory
Maternity Pay
You must send form SMP1. See page 2 of
the Notes sheet.
If you have worked for an employer
You must send us original payslips for the
13 weeks you choose. See page 9 of the
Notes sheet.
If your baby was stillborn, please send us
the notification of stillbirth or the stillbirth
certificate. See page 6 and page 8 of the
Notes sheet.
Part 12: Declaration
Also –
If you are divorced or your civil
partnership has been dissolved
Please send the original, not a photocopy
of your decree absolute or dissolution of
Civil Partnership formal order.
If you were not employed or self-
employed, but taking part in activities
related to the business of your self-
employed spouse or civil partner
Please send us your original marriage or
civil partnership certificate, if you have it. Do
not send us a photocopy.
MA1 05/18
Please do not send:
l bound documents
l unopened wages
l poor quality wage slips (please obtain duplicates before sending)
If you are sending documents after you have submitted your claim form, attach
a cover note with your name, address and NI number.
Save
20
Part 12: Declaration continued
l Check that you have answered all the questions on this form that apply to you.
l Check you are sending us all the documents we have asked for. Use the list on page 19
of this claim form. Your benefit may be delayed if you do not send us all the
documents we need.
l Send your form and documents to the office that deals with your benefit. You can find
out which office deals with your benefit below.
Please keep the MA1 Notes and MA1 Table for your information, do not return them with
your MA1 claim form.
l I declare that the information I have given on this form is correct and complete as far as
I know and believe.
l I understand that if I knowingly give information that is incorrect or incomplete,
mybenefit may be stopped and I may be liable to prosecution or other action.
l I understand that I must promptly tell the office that pays my benefit of anything that
may affect my entitlement to, or the amount of, that benefit.
l I agree that
– the Department for Work and Pensions
– any health care professional advising the Department
– any organisation with which the Department has a contract for the provision of
medical services
may ask any of the people or organisations mentioned on this form for 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 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.
This is my claim for Maternity Allowance.
Signature Date
Do not sign and date this form earlier than the 14th week before
the week your baby is due.
If you have filled in and signed this form for someone
else, please tick here.
MA1 05/18
Please remember to sign and date the form after
printing.
Save
21
Part 13: What to do now
If you live in England, Scotland or Wales, send your form and documents to:
Wrexham Maternity Allowance
Mail Handling Site A
Wolverhampton
WV98 1SU
English speakers phone
Welsh speakers phone
0800 169 0283
0800 169 0296
Textphone users with speech
or hearing difficulties use
0800 169 0286
If you are claiming from abroad, send your form and documents to:
International Pension Centre
The Pension Service 11
Mail Handling Site A
Wolverhampton
WV98 1LW
Phone: 0191 218 7644 (or +44 191 218 7644 when calling from abroad)
Textphone users with speech or hearing difficulties use 0191 218 7280
(or +44 191 218 7280 when calling from abroad)
Fax: 0191 218 7147
E-mail: tvp.internationalqueries@dwp.gsi.gov.uk
Or you can find out more at
www.gov.uk/international-pension-centre
If you live in Northern Ireland, get a claim form from:
www.nidirect.gov.uk/maternity-allowance
MA1 05/18
Save
22
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
For more information please contact Jobcentre Plus.
Part 15: Our service standards
When we collect information about you we may use it for any of our purposes.
These include dealing with:
l social security benefits and allowances
l child support
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, visit our website at
www.gov.uk/dwp/personal-information-charter or contact any of our offices.
Part 14: How the Department for Work and
Pensions collects and uses information
MA1 05/18
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