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SC1 Form (London Institute of Management and Technology)

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Incapacity Benefit is a social security benefit for people who have an
illness or disability. Sick or sickness is now referred to as illness or
disability.
You may be able to get Incapacity Benefit if you have an illness or
disability and
l you are unemployed, or
l you are self-employed, or
l you work for an employer but you cannot get Statutory Sick Pay
(SSP) or you have been getting SSP and this has now stopped.
Statutory Sick Pay (SSP) is money paid by employers to employees
who are away from work for 4 days or more in a row because of their
illness or disability.
People who have special medical treatment may get Incapacity
Benefit instead of SSP even if they work for an employer.
By
special medical treatment we mean
l dialysis
l radiotherapy
l chemotherapy
l plasmapheresis
l total parenteral nutrition for gross impairment of enteric function.
You can find out more about Incapacity Benefit in leaflets
IB1JP A
guide to Incapacity Benefit - Information for new customers or
DHC1JP A guide for disabled people, those with health conditions,
and carers. You can get these leaflets from Jobcentre Plus, or visit our
website at www.dwp.gov.uk
You may need to attend a work focused interview with a personal
advisor. If you do not attend without good reason your benefit may be
affected.
What is Incapacity Benefit?
SC1 Notes 04/07
Claim pack for Incapacity Benefit
Part of the Department for
Work and Pensions
Notes sheet
Page 1 of 48 of this pdf
24-May-07
National textphone number 0800 023 4888
National number 0800 055 6688
To find out where to send your claim, please telephone:
2
Who you can claim extra Incapacity Benefit for?
Claiming extra Incapacity Benefit for an adult
If you have any children or qualifying young persons living with you
You may be able to get extra Incapacity Benefit for
l your spouse,
l civil partner, or
l someone who looks after children or qualifying young persons for you.
If you are claiming for a spouse, civil partner or someone looking
after children or qualifying young persons for you
If you are claiming an increase of Incapacity Benefit for an adult, we may
need them to go to a work focused interview with a personal adviser.
They will not have to go to a work focused interview unless you have
been claiming Incapacity Benefit for 26 weeks or more. We will let them
know if they have to go.
If they do not take part in the work focused interview without good reason
your benefit may be affected.
If you do not have any children or qualifying young persons
You may be able to get extra Incapacity Benefit for your spouse or civil
partner if they are aged 60 or over. They will not need to go to a work
focused interview.
We use
child to mean a person aged under 16 for whom Child Benefit is
being paid.
We use
qualifying young person to mean a person aged 16 to 20 for
whom Child Benefit is being paid.
How to claim?
Phone Jobcentre Plus or fill in claim form SC1 that comes
with this pack.
Please use a pen only when completing the form.
Make sure you read the rest of these notes. They will help you to make
your claim.
Signing the form for someone else
The claim form should only be signed by someone else if
l the person who is making the claim is not mentally able to act on their
own behalf, and
l someone is willing to act on their behalf in all social security matters,
including telling us about any change in their circumstances and
collecting monies for them. Someone accepted by the Department to
act on someone’s behalf is known as the appointee.
Someone who is physically disabled but mentally able will not normally
need someone to act for them.
If someone applies to act on someone else’s behalf we will
l arrange a visit to the person whose claim it is and the person making
the application to act, and
l decide whether the person needs someone to act on their behalf for all
social security matters, and
l explain the responsibilities that person would be taking on.
Any benefit due will not be paid until the process is complete.
If someone has power of attorney or any legal authority to act on behalf
of the person making the claim, then that person should sign the claim
form and enclose a copy of the authority with the claim form. The copy
must be certified and signed by a solicitor as a true copy.
Page 2 of 48 of this pdf
24-May-07
3
When to claim
If you are
l unemployed, or
l self-employed,
phone Jobcentre Plus or fill in claim form SC1 as soon as you can after
you have been unable to work for 4 days or more in a row because of
your illness or disability,
or
if you work for an employer but you cannot get Statutory Sick Pay (SSP)
or SSP has stopped, get form SSP1 from your employer. Phone
Jobcentre Plus or fill in claim form SC1 as soon as you can.
Do not delay in making your claim for benefit. If you wait, you could lose
money.
Please note that we cannot pay your benefit for a period more than
3 months before the date we receive your claim.
If you need medical advice or treatment, go to your doctor straight away.
You do not normally need a medical certificate from your doctor for the first
week that you are unable to work.
However, if you are claiming Incapacity Benefit and have had one or more
short spells of incapacity totalling more than 7 days within the last 8 weeks,
you will need to get a medical certificate from your doctor from the first day
of this claim.
If you have not claimed Incapacity Benefit within the last 8 weeks then if you
are still unable to work after 7 days, you will need to see your doctor and
obtain a medical certificate from the 8th day. Forward this medical certificate
to Jobcentre Plus.
Medical certificates are also called sick notes, doctor’s notes or doctor’s
statements.
If you have special medical treatment, phone Jobcentre Plus or fill in
claim form SC1 as soon as your treatment means that you cannot work
for 2 days or more.
These days do not have to be in a row, but they must be within a 7 day
period starting with any day of the week.
If you have special medical treatment every week, phone Jobcentre Plus
or fill in claim form SC1 for the first week that you have your treatment.
Please get a medical certificate or letter from your doctor or hospital. This
should say
l what treatment you are getting
l which days of the week you cannot work
l how long your treatment will last.
Jobcentre Plus will need the medical certificate or letter as soon as you can.
Do not delay making your claim to benefit.
You can find the address of Jobcentre Plus on the advert in the business
numbers section of the phone book. Look under
Jobcentre Plus.
If you have special medical treatment occasionally, phone Jobcentre
Plus or fill in claim form SC1 each time that your treatment means that
you cannot work for 2 days or more.
Page 3 of 48 of this pdf
24-May-07
Other help
4
Disability Living Allowance
This is a social security benefit for people with an illness or disability who need
l help with getting around, or
l help with personal care, or
l help with both of these.
If you want to find out more about this, get leaflet
DLAA5DCS Disability Living
Allowance from Jobcentre Plus.
Incapacity Benefit for young people
Incapacity Benefit is available for young people aged 16 or over but under 20,
or aged 20 or over but under 25 in some cases, who
l have been incapacitated early in life
l are unable to work because of illness or disability
l have not paid enough National Insurance (NI) contributions to be able to get
Incapacity Benefit under the normal rules.
For more detailed information about Incapacity Benefit, get leaflet
IB1JP A
guide to Incapacity Benefit - Information for new customers from Jobcentre
Plus.
Industrial Injuries Disablement Benefit
This is a social security benefit for people who are disabled because of
l an accident at work, or
l an industrial disease.
If you want to find out more about this, get leaflet
IIDBAA5JP Industrial Injuries
Disablement Benefit - Accidents or leaflet IIDBDA5JP Industrial Injuries
Disablement Benefit (diseases) from Jobcentre Plus.
Working Tax Credit
This is a tax credit to top up the earnings of working people. You can claim
Working Tax Credit if
l you are aged 16 or over, and
l you work at least 16 hours a week, and
l you or your partner are responsible for a child or qualifying young person, or
l you have a disability which puts you at a disadvantage in getting a job, or
l you or your partner are aged 50 or more and are returning to work after a
spell on qualifying out of work benefits.
If you do not have children, qualifying young persons or a disability that puts
you at a disadvantage in getting a job, you can also claim Working Tax Credit if
l you are aged 25 or over, and
l you work at least 30 hours a week.
The Working Tax Credit is available to self-employed people and employees. If
you want to know more about Working Tax Credit contact HM Revenue &
Customs on the numbers listed on
page 5.
If you work for an employer or you worked for an employer on the date
you are claiming Incapacity Benefit from, you may be able to get Statutory
Sick Pay (SSP) instead.
SSP is money paid by employers to employees who are away from work
for 4 days or more in a row because of their illness or disability.
If you want more information about SSP, get in touch with your employer.
Statutory Sick Pay (SSP)
Page 4 of 48 of this pdf
24-May-07
Other help
– continued
Child Tax Credit
You cannot claim an increase of benefit for children or qualifying young
persons, but you can claim Child Tax Credit instead. To find out more about
Child Tax Credit visit www.hmrc.gov.uk
You can claim online too.
You can also phone HM Revenue & Customs by calling the Helpline on the
following numbers:
England, Scotland and Wales –
0845 300 3900
Northern Ireland only – 0845 603 2000
Textphone for people with hearing or speech difficulties:
England, Scotland and Wales – 0845 300 3909
Northern Ireland only – 0845 607 6078
Lines open 8am–8pm seven days a week except Christmas Day, Boxing Day,
New Year’s Day and Easter Sunday.
If you need help or a form in Welsh, please phone
0845 302 1489. Lines are
open 8.30am–5pm Monday to Friday.
Income Support
You may be able to get Income Support if you cannot get Incapacity Benefit, or
if your Incapacity Benefit does not give you enough money to live on. If you
think you may be able to get Income Support, you should claim straight away
because Income Support will only be payable from the date your claim is
received by Jobcentre Plus. Ask for leaflet DHC1JP A guide for disabled
people, those with health conditions, and carers from Jobcentre Plus
Pension Credit
You may be entitled to Pension Credit if you are aged 60 or over. You can
apply for Pension Credit by phoning The Pension Service on 0800 99 1234.
For people with speech or hearing difficulties using a textphone the number is
0800 16 90 133. Lines are open 8.00am to 8.00pm Monday to Friday and
9.00am to 1.00pm on Saturday.
You may also apply on the internet. Visit the website at
www.thepensionservice.gov.uk/pensioncredit
For general information about Pension Credit see leaflet PC1L Pension Credit.
You can get it from Jobcentre Plus or your pension centre.
Jobseeker’s Allowance
This is a social security benefit for people who are unemployed and looking for
work.
NHS charges
You may be able to get help with paying for things like NHS prescriptions and
NHS dental treatment.
Housing Benefit
Housing Benefit is paid by local councils to people who need help to pay their
rent. Housing Benefit is not paid to help with the cost of mortgage interest
payments.
Council Tax Benefit
You may be able to get Council Tax Benefit from your local council
to help with paying your council tax.
You can find out more about these benefits from Jobcentre Plus, or visit our
website at
www.dwp.gov.uk
5
Page 5 of 48 of this pdf
24-May-07
6
Making payments to you
We normally pay benefit directly into an account. This is the safest way
to pay you and lets you choose how and when you get your money. You
can use a bank, building society or other account provider. Most accounts
allow you to make savings on some of your bills by paying them by Direct
Debit. You may be able to use a cash machine, which will usually mean
you can get your money at any time of the day or night. Most of these
machines can be used for free, but some of them may charge you to take
your money out. If so, you will be warned by a message on the screen.
This will give you the opportunity to cancel your transaction without being
charged. There are arrangements with some banks and building societies
to let you collect cash from many of their accounts over the counter at post
offices.
How your money is worked out
If you are entitled to Incapacity Benefit for less than a whole week, the
amount that you get for each day will be the weekly amount divided by 7.
When we work out your Incapacity Benefit we round the amounts to the
nearest penny.
You will not normally get any Incapacity Benefit for the first 3 days that
you cannot work because of your illness or disability. We call these
waiting days.
You may get Incapacity Benefit for these 3 days if
l you have been getting Incapacity Benefit or Statutory Sick Pay (SSP)
within 8 weeks of your present claim, or
l you have been getting Incapacity Benefit and you are entitled to the
104 week benefit protection, or
l you have attended a recognised training course and it is 2 years or
less since you last claimed Incapacity Benefit.
You may also get Incapacity Benefit for these 3 days if you have
been getting
l Disabled Person’s Tax Credit, or
l a disability element of Working Tax Credit, whether or not it is paid, or
l you are paid Working Tax Credit or Child Tax Credit at a higher rate
than the family element,
and
l it is 2 years or less since you last claimed Incapacity Benefit.
Pension income
We will look to see if you have a pension income.
We use pension income to mean money you have coming in from one of
the following pensions
l occupational pension
l personal pension
l public service pension
l stakeholder pension
l a pension from a self-employed pension scheme
l permanent health insurance payments arranged by an employer where
the contract of employment has ended
l pension protection fund payments due to employer insolvency.
Page 6 of 48 of this pdf
24-May-07
How your money is worked out
– continued
7
The pension income rules do not apply
l to any customer receiving the Disability Living Allowance care
component at the highest rate, or
l if your Incapacity Benefit entitlement began prior to 6 April 2001, or
l if your current claim links to a claim made before 6 April 2001.
Your pension will be managed by a
pension provider. This is usually
an organisation like a former employer or insurance company.
If you have a pension income before tax of over £85.00 a week, your
Incapacity Benefit and any Incapacity Benefit you are claiming for
anyone else, will decrease.
If part of your pension is paid to your ex-spouse or ex-civil partner
under an ear marking order, only the part that is payable to you
counts as pension income. An ear marking order is where a Court has
decided, under the Matrimonial Causes Act 1973, that your pension
provider must pay part of your pension to an ex-spouse or ex-civil
partner.
If part of your pension has been transferred to your ex-spouse or
ex-civil partner under a pension sharing order, the amount that has
been transferred does not count as pension income. A pension
sharing order is where part of your occupational pension is
transferred to an ex-spouse or ex-civil partner. This is usually a one-off
payment and is transferred to them at the time of divorce or
dissolution of civil partnership.
Special Rules
Some people suffer from a terminal illness. The Special Rules apply to
people who are not expected to live longer than 6 months because of
an illness. But it is, of course, impossible to say exactly how long a
person will live. Getting Incapacity Benefit under the Special Rules
means that you will get the long-term rate of Incapacity Benefit when
you have been getting Incapacity Benefit for 28 weeks.
Tell us if you think the
Special Rules apply to you. Please see Part 2
of the claim form.
If you think you qualify for Incapacity Benefit under the
Special Rules,
you can also claim Disability Living Allowance if you have not already
done so.
For people who are getting Disability Living Allowance
People who are getting the highest rate care component of Disability
Living Allowance can get the long-term rate of Incapacity Benefit
when they have been getting Incapacity Benefit for 28 weeks. This
would not normally be payable until they have been getting Incapacity
Benefit for 52 weeks.
Page 7 of 48 of this pdf
24-May-07
8
Working while claiming benefit
Permitted work
Permitted work allows people to work while still getting an Incapacity
Benefit or National Insurance credits because of illness or disability.
You can
l work for less than 16 hours a week, on average, and earn up to a
set amount each week for 52 weeks, or
l work for less than 16 hours a week, on average, and earn up to
£86.00 each week for as long as your illness or disability is
considered sufficiently severe that you meet the threshold of
incapacity without undergoing a medical assessment, or
l work and earn up to £20 a week, at any time, for as long as you
are on the benefit, or
l do supported permitted work and earn up to a set amount each
week for as long as you are on the benefit.
Supported permitted work means work that is supervised by
someone who is employed by a public or local authority, or a
voluntary organisation, whose job it is to arrange work for people
with disabilities.
If you want more information about permitted work and the amounts
you can earn, get in touch with the Incapacity Benefit section at the
office that deals with your benefit. You should use tell your benefit
office about any work you want to do and complete form
PW1.
Voluntary work
You may be able to get Incapacity Benefit if you do some voluntary
work. The work must be for someone other than a member of your
family and you must not get any payment for it, other than
reasonable expenses.
Where to get help and advice
For information about your own claim
Get in touch with 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.
For general information about this benefit
Ring the Benefit Enquiry Line for people with disabilities. The
number is 0800 88 22 00. The person you speak to will be able to
give you general advice about the benefit and they can tell you
about other organisations that may be able to help you.
If you have problems with hearing or speaking and use a textphone,
ring
0800 24 33 55. If you do not have your own textphone system,
they are available in some libraries and Citizens Advice Bureau.
If you live in England or Wales you can get free, independent and
confidential advice about Incapacity Benefit and other benefits. Call
Community Legal Services Direct on
0845 345 4 345. You can visit
their website at www.clsdirect.org.uk
For more information about benefits and services visit our website at
www.dwp.gov.uk
Page 8 of 48 of this pdf
24-May-07
SC1 04/07
Your claim for Incapacity Benefit
Part of the Department for
Work and Pensions
If you need help to fill in this form
If you need help to fill in this form, you can ask someone else to fill it in
for you, or you can contact your local office.
If you are filling this form in for someone else, see
Section 3, Part 20.
Please remember to fill in the rest of the form with their details, not yours.
Benefit you may get because of this claim will be paid more quickly if you
l answer all the questions on this form that apply to you or the person
you are claiming an increase of benefit for, and
l provide all the documents we ask for, and
l attend work focused interviews when required.
If you cannot do this, get in touch with us straight away.
If you do not, you may lose benefit.
Work focused interviews
You may have to attend a work focused interview with a personal advisor.
If you do not attend without good reason your benefit may be affected.
Before you fill in this form please read the notes that come in this
pack. To help you decide whether you should complete this form or
not, answer the questions below and follow the instructions.
Do you work for an employer?
Has your employer issued you
with form SSP1?
You must send us a separate
form SSP1 for each job you
have.
Do you have any special
medical treatment?
Special medical treatment
is explained in page 1 of
SC1 Notes.
Do you have more than
one job?
No
Yes
Please go to next question.
Please go to
Part 1.
No
Yes
Please go to Part 1.
Please go to next question.
No
Yes
Please go to Part 1.
Please get in touch with your employer
and ask about Statutory Sick Pay (SSP).
See page 4 of the SC1 Notes.
No
Yes
How many more jobs do you have?
Please go to next question.
Please go to next question.
There are 3 sections in this form. Everyone should fill in sections 1 and 3.
You only need to fill in section 2 if you want to claim extra Incapacity Benefit
for another adult.
SSP1 received No Yes
For office use
Issue dateOffice code
/ /
Page 9 of 48 of this pdf
24-May-07
About you
Part 1
Section 1 Claiming for yourself
Surname or family name
Other names you use now – in full
Mr/Mrs/Miss/Ms
Postcode
All previous surnames or family
names you have used.
Code Number
Daytime phone number
if you have one
Address
Date of birth
//
Code Number
Daytime textphone number
for people with speech or
hearing problems
Postcode
Address, if different in the
last 3 years.
If you need to tell us about
more than one address, use
the space in Part 19.
2
Home Work Mobile Fax
What is this number?
Please tick.
National Insurance (NI) number
You can get this from your NI
number card, letters about your
benefit or payslips.
Letters Numbers Letter
Marital or civil status
married or civil partner
widowed or surviving civil partner
single
divorced or
civil partnership dissolved
separated
If you do not know your NI
number, have you ever had
one or used one?
No
Yes
l Please tell us about any other personal details you think we should know about in
Part 19 Other information. For example, other names or other previous addresses.
Page 10 of 48 of this pdf
24-May-07
3
About your illness or disability
What date do you want to claim
Incapacity Benefit from?
You may have to attend a work focused interview with a personal advisor.
If you do not attend without good reason your benefit may be affected.
Did you work a night shift which
included midnight on the date
you last worked?
Do you have any special
medical treatment?
Please read page 3 of SC1 Notes
By special medical treatment we mean
l dialysis
l radiotherapy
l chemotherapy
l plasmapheresis
l total parenteral nutrition for gross
impairment of enteric function.
/ /
What was the last date you
l worked for an employer, or
l worked as a self-employed
person, or
l you claimed Jobseeker’s
Allowance, or
l received National Insurance
(NI) credits because you
attended a Jobcentre Plus
office or Jobcentre?
//
No
Yes
Part 2
No
Yes
What date and time did you
start the shift?
//
What date and time did you finish
the shift?
//
Please tell us about it below
Are you claiming Jobseeker’s
Allowance at a Jobcentre Plus
office or Jobcentre?
No
Yes
Fill in your ES40 and send it back to the Jobcentre Plus
office or Jobcentre as soon as you can.
This will help us to deal with your claim more quickly.
Are you receiving National
Insurance (NI) credits only,
because you attend a Jobcentre
Plus office or Jobcentre?
No
Yes
Fill in your ES40 and send it back to the Jobcentre Plus
office or Jobcentre as soon as you can. This will help us
deal with your claim more quickly
am/pm
am/pm
Are you registered blind with
a local authority in England
or Wales, or certified as blind
with a regional or islands
council in Scotland?
No
Yes
Please tell us the name of the local authority or council.
Page 11 of 48 of this pdf
24-May-07
4
About your illness or disability – continued
Part 2
Please give brief details of your
illness or disability.
We need to know what your
doctor says is wrong with you and
how this stops you from working.
Have you been in hospital as
an in-patient since your illness
or disability began?
Details of your illness or disability
Date you went into hospital
Please tell us about it below.
No
Yes
/ /
/ /
Name and address of the
hospital
Postcode
Have you come out of
hospital?
Date you came out of hospital.
No
Yes
Have you claimed Statutory
Sick Pay or Incapacity Benefit
in the 8 weeks before this
claim?
Please provide a medical certificate from your first day
of illness or disability.
Please provide a medical certificate from your 8th day
of illness or disability.
No
Yes
Medical certificate received No Yes
For office use
/ /
Are you expecting a baby?
What date is your baby expected?
No
Yes
/ /
Have you had a baby in the
39 weeks before the date you
are claiming Incapacity Benefit
from?
If you were expecting your baby
on or before 31 March 2007, you
may have been paid Maternity
Allowance for a period of up to
26 weeks.
If you were expecting your baby
on or after 1 April 2007, you may
have been paid Maternity
Allowance for a period of up to
39 weeks.
What date was your baby born?
No
Yes
Page 12 of 48 of this pdf
24-May-07
5
About your illness or disability – continued
Part 2
Details of your illness or disability continued
Do you think your illness or
disability is because of an
industrial disease caused by
conditions at work while
working for an employer?
If you are not sure whether the
disease you have is an industrial
disease, tick Yes.
You may be able to get Industrial Injuries Disablement
Benefit. We will send you leaflet
IIDBAA5JP Industrial
Injuries Disablement Benefit - Accidents to read. This will
tell you about the benefit and how to claim it.
We will also send you leaflet
IIDBDA5JP Industrial Injuries
Disablement Benefit (diseases) to read, which will tell you
about prescribed diseases.
No
Yes
Special Rules
Please tick this box if you think
the Special Rules apply to you.
The Special Rules are explained
on page 7 of SC1 Notes.
Ask your doctor or specialist for a
DS1500 Report. This 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.
If you cannot get your
DS1500 Report in time, do not delay in
making your claim to benefit. Provide the DS1500 Report as
soon as you can.
Have you claimed Disability
Living Allowance under the
Special Rules which apply to
that benefit but have not yet
heard if you will get it?
If you have asked for a DS1500 Report for your claim to
Disability Living Allowance, you do not need to get another.
Send the
DS1500 Report with your Disability Living
Allowance claim if you are claiming Disability Living
Allowance and Incapacity Benefit at the same time.
No
Yes
About your doctor
Please tell us the name and
address of the doctor who is
signing your medical
certificates.
Postcode
Going back to work
Do you know when you will be
well enough to work again?
No
Yes
What date will you go back to work?
//
Do you think your illness or
disability is because of an
accident at work while working
for an employer?
You may be able to get Industrial Injuries Disablement
Benefit. We will send you leaflet IIDBAA5JP Industrial
Injuries Disablement Benefit - Accidents to read. This will
tell you about the benefit and how to claim it.
No
Yes
Page 13 of 48 of this pdf
24-May-07
6
About your illness or disability – continued
Part 2
Going back to work – continued
Will you go back to work on a
night shift which includes
midnight?
No
Yes
What date and time will you
start the shift?
//
What date and time will you finish
the shift?
//
Please tell us about it below
am/pm
am/pm
If you do not have a job to go
back to, tell us when you will
be well enough to work.
//
What date did you start work
or training?
//
About the 104 weeks before this new illness or disability began
Have you been off work due to
illness or disability, during the
104 weeks before the date you
are claiming Incapacity Benefit
from?
No
Yes
Did you start work or training
within 1 month of leaving
benefit?
No
Yes
If
l you have ticked Yes, and
l the date you are awarded benefit from is within 104
weeks of you leaving benefit and returning to work or
training
you may qualify for a
104 week linking. If you qualify for a
104 week linking, you may be able to return to benefit at
your previous rate.
SSP1 received No Yes
For office use
Were you employed during the
8 weeks before the date you
are claiming Incapacity Benefit
from?
Were you off work because of
your illness or disability for
4 days or more in a row during
the 8 weeks before the date
you are claiming Incapacity
Benefit from?
No
Yes
Please go to Part 3.
No
Yes
Please go to Part 3.
What you were doing in the 8 weeks before your illness or disability began may
affect when you start to get Incapacity Benefit.
About the 8 weeks before your illness or disability began
Page 14 of 48 of this pdf
24-May-07
7
About education, training and apprenticeships
Part 3
Have you attended a course
of education, training or
apprenticeship in the last
4 years?
Please tell us about it below.
No
Yes
Name of the course, training
scheme or apprenticeship
Postcode
Name and address of the
school, training centre,
college or university
Number of hours spent attending
the course each week
hours
Date education, training
or apprenticeship started
//
Date education, training
or apprenticeship ended
If it is still continuing tick this box
/ /
What was the course?
Education
Training
Apprenticeship
Are you getting, or did you get,
a grant or training allowance?
Please tell us about it below.
No
Yes
£ every
How much do you get and
how often?
Postcode
Give name and address of
who pays, or paid, the grant
or allowance
You must send us any documents that show when you did
the course, training or apprenticeship and how much grant or
allowance was paid.
Page 15 of 48 of this pdf
24-May-07
8
About self-employment
Part 4
Proof received Training
Education
Apprenticeship
For office use
Please give brief details of the
work you normally do.
Have you worked as or been
classed as a self-employed
person in the 21 weeks before
the date you are claiming
Incapacity Benefit from?
What is your usual occupation?
Period of self-employment
How many hours a week do
you normally work?
Please go to
Part 5.
Please tell us about this self-employed work.
No
Yes
Do you also work for
an employer?
Please go to Part 5.
No
Yes
hours
from to
// //
Are you a company director?
Please go to Part 6.
Please provide form
SSP1.
Please go to Part 5.
No
Yes
Page 16 of 48 of this pdf
24-May-07
9
For unemployed people and people who
work for an employer
Part 5
What is your usual occupation?
Have you been given
a Statutory Sick Pay Leaver’s
Statement, SSP1(L) by your
latest employer?
Include the SSP1(L) with this claim form.
If you do not, benefit you can get because of this
claim may be delayed.
No
Yes
Have you worked or been
employed in the 21 weeks
before the date you are
claiming Incapacity Benefit
from?
Include periods of leave, career
breaks, training.
Please go to
Part 6.
Please tell us about this.
No
Yes
SSP1L received No Yes
For office use
Employer 1
Employer’s name and address
Job title
Phone number
Fax number
Postcode
Code Number
Code Number
Pay reference or staff number
What were the main activities of
the job?
Period of employment
Hours worked each week
hours
from to
// //
Page 17 of 48 of this pdf
24-May-07
10
For unemployed people and people who work for
an employer – continued
Part 5
Employer 2
Employer’s name and address
Job title
Phone number
Fax number
Postcode
Code Number
Code Number
Pay reference or staff number
What were the main activities of
the job?
Period of employment
Hours worked each week
hours
from to
/ / / /
Employer 3
Employer’s name and address
Job title
Phone number
Fax number
Postcode
Code Number
Code Number
Pay reference or staff number
What were the main activities of
the job?
Period of employment
Hours worked each week
hours
from to
/ / / /
l If you worked for or have been employed by more than 3 employers in the 21 weeks before
this period of sickness began, tell us about the other employers in Part 19 Other information.
Page 18 of 48 of this pdf
24-May-07
11
For unemployed people and people who
work for an employer
– continued
Part 5
Are you also self-employed?
Are you still working?
What type of work do you do?
Please tell us about it below.
No
Yes
What date did you last work as self-employed?
No
Yes
//
About time you have spent abroad
Part 6
We need to know about time you have spent abroad.
We use abroad to mean any country outside the United Kingdom (UK).
The UK is England, Scotland, Wales and Northern Ireland, including territorial waters
next to the UK. But the UK does not include the Isle of Man or the Channel Islands.
Have you been abroad at any
time during the 5 years before
the date you are claiming
Incapacity Benefit from?
Tick No, if you went abroad just
for a holiday.
No
Yes
Which countries did you go to, and when?
/ /
/ /
Country
From To
/ /
/ /
Country
From To
Tick the description that
applies to your time abroad.
I worked for an overseas employer
I worked for a UK employer
I was self-employed
I was getting money from a social security
scheme of the country I was staying in
Other – please give details below
Have you been abroad at any
other time?
Tick No, if you went abroad just
for a holiday.
No
Yes
Which countries did you go to, and when?
Please go to Part 7.
/ /
/ /
Country
From To
/ /
/ /
Country
From To
Page 19 of 48 of this pdf
24-May-07
12
About benefits and other entitlements
Part 7
Are you getting any other
benefits?
Tick Yes even if you are waiting
to hear about a benefit.
For example,
l Bereavement benefits
l Guardian’s Allowance
l Income Support
l Jobseeker’s Allowance
l Maternity Allowance
l State Pension
l Training Allowance
l Unemployability Supplement
l War Widow’s Pension
l Widow’s Benefit
Tick
No, if you just get Child
Benefit. We will ask you about
this later in the form.
Name of benefit
Reference number, if known
No
Yes
Please tell us about the benefits below.
Name of benefit
Reference number, if known
Name of benefit
Reference number, if known
Are you, or your partner
getting or waiting to hear
about Pension Credit?
Please tell us how much is paid and how often.
No
Yes
£ every
Have you ever made a claim
for Carer’s Allowance?
Tick Yes, if your claim was
disallowed.
Please tell us the date
you made this claim.
No
Yes
//
/ /
/ /
From To
Have you been paid any
Statutory Maternity Pay (SMP)
by an employer?
If this has now stopped,
please give the date of
the last payment.
No
Yes
//
Have you been paid any
Statutory Adoption Pay (SAP)
by an employer?
If this has now stopped,
please give the date of
the last payment.
No
Yes
//
Have you qualified for a
disability element of Working
Tax Credit, whether or not it
is paid?
What period was it awarded for?
No
Yes
Page 20 of 48 of this pdf
24-May-07
13
About benefits and other entitlements
– continued
Part 7
Have you been getting Working
Tax Credit or Child Tax Credit at
a higher rate than the family
element, up to the day before
the date you are claiming
Incapacity Benefit from?
Tick Yes, if you are not sure of the
dates.
No
Yes
Are you getting the highest
rate care component of
Disability Living Allowance?
No
Yes
Have you claimed Disability
Living Allowance but not yet
heard if you will get it?
No
Yes
Are you getting Industrial
Injuries Disablement Benefit?
No
Yes
Are you getting a War
Disablement Pension?
No
Yes
Is anyone getting extra money
added onto their social security
benefit for you?
Tick Yes, if anyone is waiting to
hear about getting extra money
added onto their social security
benefit for you.
No
Yes
Please tell us about the person who is getting, or
waiting to hear about getting, this extra money.
Their surname
Other names
Mr/Mrs/Miss/Ms
Postcode
Address
Their National Insurance (NI)
number
Letters Numbers Letter
Please tell us which benefits they
are getting or waiting to hear
about.
Page 21 of 48 of this pdf
24-May-07
14
Pension income
Part 8
We need to know about any pension income that you have as it may affect the
amount of benefit you can get. Please provide proof of your pension income.
For information on pension providers, pension income and how it may affect you,
please read page 6 of SC1 Notes.
How much pension is due to
you before any deductions?
Your first (or only) personal pension income
Please tell us the name and
address of your pension
provider
Please tell us your pension
provider’s phone number
What is your pension
reference number?
Do you have any pension
income?
If you have answered No to both
of the above questions go to
Permanent health insurance on
page 16 .
Are you waiting to hear about
any pension income?
If Yes, let us know as soon as
your pension income has been
awarded.
When will you get the first
payment which includes the
change?
For example 15 May.
How often is your pension paid?
For example weekly, four-weekly,
monthly, quarterly.
When is the amount of your
pension due to change?
For example 1 May.
How much pension are you
paid after any deductions?
Important – please provide proof of your pension income,
this could be one of the following
l a letter of entitlement from your employer or insurance company who
pay the pension
l a payment advice notice from your pension provider
l a current wage slip showing details of your pension income
We need to see original documents, photocopies are not acceptable.
Failure to do so may affect your claim.
No
Yes
No
Yes
Please give details below.
Postcode
Code Number
£
£
Page 22 of 48 of this pdf
24-May-07
15
Pension income – continued
Part 8
How much pension is due to
you before any deductions?
Your second personal pension income
Please tell us the name and
address of your pension
provider
Please tell us your pension
provider’s phone number
What is your pension
reference number?
When will you get the first
payment which includes the
change?
For example 15 May.
How often is your pension paid?
For example weekly, four-weekly,
monthly, quarterly.
When is the amount of your
pension due to change?
For example 1 May.
How much pension are you
paid after any deductions?
Postcode
Code Number
£
£
Pension paid to you as a beneficiary
Do you get any pension
payment made to you as a
beneficiary from the death of a
member of a pension scheme?
Name and address of the pension
provider
The pension provider’s phone
number
How much is the pension
after
any deductions?
How often is your pension paid?
For example weekly, four-weekly,
monthly, quarterly.
No
Yes
Please give details below.
Postcode
Code Number
£
Page 23 of 48 of this pdf
24-May-07
16
Pension income – continued
Part 8
You can use this space to tell
us if you have any other
pension income, or anything
else you think we might need
to know about your pension
income.
For example, give the reason and
amount for any deductions that
are taken from your pension
income.
Important – please provide proof of your permanent health
insurance payment, this could be one of the following
l a letter of entitlement from your employer or insurance company who
pay the pension
l a payment advice notice from your pension provider
l a current wage slip showing details of your pension income
We need to see original documents, photocopies are not acceptable.
Failure to do so may affect your claim.
Have you contributed more than
half the premiums towards any
permanent health insurance
payment?
Do you get a permanent health
insurance payment?
Please go to Part 9.
Name and address of the
employer paying the remaining
premium
Their phone number
Has your contract of
employment ended with
this employer?
Permanent health insurance
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.
No
Yes
No
Yes
No
Yes
No
Yes
When did it end?
Postcode
Code Number
/ /
Proof of pension income received No Yes
For office use
Page 24 of 48 of this pdf
24-May-07
17
Tax information
Part 9
If you qualify for Incapacity Benefit, it may affect the amount of
income tax you have to pay.
Your answers to these questions will not affect whether you get
Incapacity Benefit, but they will help us to try to make sure you are
given the right tax code and that you pay the right amount of tax.
Tax district and tax reference
number
You can find this above your NI
number on HM Revenue & Customs
tax forms. Or you can ask your
employer or your pension provider.
Even if you do not know your tax
reference number, send this form
back to us straight away.
Please send us your form P45, if you have one.
Blind person’s allowance
Tick this box if you are
l registered blind with a local
authority in England or
Wales, or
l certified as blind with a
regional or islands council
in Scotland
and you want to claim this
allowance.
Will your employer continue to
pay you whilst you are off work
due to illness or disability?
If you are self-employed will
your business now stop
because you are sick?
No
Yes
No
Yes
Please tell us the name of the local authority.
P45 received No Yes
For office use
Page 25 of 48 of this pdf
24-May-07
Section 2 Claiming extra benefit for
another adult
Claiming extra Incapacity Benefit for an adult
If you want to claim extra Incapacity Benefit for
l your spouse, or
l civil partner, or
l someone who looks after children or qualifying young persons for you
please complete Parts 10 to 15 and Part 17 of this section.
We use
child to mean a person aged under 16 for whom Child Benefit is
being paid.
We use
qualifying young person to mean a person aged 16 to 20 for
whom Child Benefit is being paid.
If you are claiming for a spouse, civil partner or someone looking
after children or qualifying young persons for you
If you are claiming an increase of Incapacity Benefit we may need the
person you are claiming for to go to a work focused interview with a
personal adviser.
They will not have to go to a work focused interview unless you have
been claiming Incapacity Benefit for 26 weeks or more. We will let them
know if they have to go.
If they do not take part in the work focused interview without good
reason your benefit may be affected.
If you want to claim extra Incapacity Benefit for a person you employ to
look after children or qualifying young persons for you, please complete
Parts 11 and 16 of this section.
Child Tax Credit
You cannot claim an increase of benefit for children or qualifying young
persons but you can claim Child Tax Credit instead. To find out more
about Child Tax Credit visit www.hmrc.gov.uk
You can claim online too.
You can also phone HM Revenue & Customs by calling the Helpline on
the following numbers:
England, Scotland and Wales –
0845 300 3900
Northern Ireland only – 0845 603 2000
Textphone for people with hearing or speech difficulties:
England, Scotland and Wales – 0845 300 3909
Northern Ireland only – 0845 607 6078
Lines open 8am–8pm seven days a week except Christmas Day, Boxing
Day, New Year’s Day and Easter Sunday.
If you need help or a form in Welsh, please phone
0845 302 1489. Lines
are open 8.30am–5pm Monday to Friday.
We will need some information about the children or qualifying young
persons before we can pay extra money for an adult.
If you do not have any children or qualifying young persons
You may be able to get extra Incapacity Benefit for your spouse or civil
partner if they are aged 60 or over. They will not need to go to a work
focused interview.
If you do not want to claim extra benefit please go to
Part 18.
18
Page 26 of 48 of this pdf
24-May-07
19
Please tell us about your spouse or civil partner or the person
who looks after children or qualifying young persons for you.
Their surname
Their other names
Their date of birth
Mr/Mrs/Miss/Ms
//
Their National Insurance (NI)
number
Letters Numbers Letter
If you claim extra money for
l a spouse, civil partner or a person who looks after
children or qualifying young persons for you
and
l they are under 60 years of age
they may have to go to a work focused interview once you
have been getting Incapacity Benefit for 26 weeks or more.
Is your spouse, civil partner or
the person looking after
children or qualifying young
persons for you living with you
now?
Do you want to claim
extra Incapacity Benefit
for
l your spouse, or
l your civil partner, or
l a person who looks after
children or qualifying young
persons for you?
No
Yes
Please complete Parts 10 to 15 and 17 of this form.
Please go to
Part 18.
No
Yes
Claiming extra benefit for another adult
Part 10
Do they normally live at a
different address to you?
What date did you
start making these
payments?
Their address
No
Yes
Please tell us about this.
Postcode
Do you send any money to
this person?
No
Yes
How much do you
send each week?
£
//
Page 27 of 48 of this pdf
24-May-07
Claiming extra benefit for another adult – continued
Part 10
If you are claiming for your spouse or civil partner
We need to see
l your marriage or civil partnership certificate, and
l the birth certificate of your spouse or civil partner.
Please enclose the certificates with this form, if you have them. We
will send them back to you as soon as we can. If you do not have
the certificates, we will write to tell you what to do. But do not delay
in making your claim to benefit.
If you want, you can bring the certificates to our office. We will give
the certificates straight back to you after we have seen them.
Remember
l we need to see the real certificates, not photocopies
l if you do not provide all the documents we ask for, benefit you
can get because of this claim may be delayed.
Are you sending your marriage
certificate or civil partnership
certificate with this form?
Are you sending the birth
certificate of your spouse or
civil partner with this form?
If you have ticked No to either
of these questions, please say
why you cannot let us see the
certificate or certificates.
No
Yes
No
Yes
Date of marriage or
formation of civil partnership
Previous surname
Evidence seen
Verified by
Checked by
Certificate(s) returned by
on (date)
Spouse or civil partner’s
date of birth
Evidence seen
Verified by
Checked by
Certificate(s) returned by
on (date)
For office use
20
Page 28 of 48 of this pdf
24-May-07
About children or qualifying young persons
Are you or anyone who lives
with you getting Child Benefit?
Before we can pay extra money for your spouse or civil partner or the person
who looks after children or qualifying young persons for you, we need to know
details of the children or qualifying young persons and Child Benefit.
Please tell us who is getting
Child Benefit.
You
Your spouse or civil partner
who lives with you
Your spouse or civil partner
who does not live with you
Your ex-spouse or
ex-civil partner
Not known
Someone who looks after children
or qualifying young persons for you
You will find the reference number on letters
sent to you about Child Benefit.
Please tell us about each child or qualifying young person. If you
need to tell us about more than 6 children or qualifying young
persons use the space in Part 19.
Does any child or qualifying
young person have a parent
who lives with you but is not
your spouse or civil partner?
Amount each week Reference number
//
//
/ /
/ /
//
//
Surname
Relationship
to you
Other names Date of birth
Male
or
female
For example, son,
niece, grandson,
stepdaughter or
none
M F
No
Yes
Please tell us about this.
£
£
No
Yes
Please give name of child or qualifying young person.
21
Part 11
Page 29 of 48 of this pdf
24-May-07
About children or qualifying young persons –
continued
Part 11
Please tell us about any changes there are likely to be in the next 2 months that
might make a difference to the amount of Child Benefit that is being paid.
For example, if a child or qualifying young person is leaving school.
Are you or your spouse or
civil partner, getting a family
benefit for a child or
qualifying young person from
another country?
The changes you must
tell us about are listed in
the notes sent to you
about Child Benefit.
No
Yes
22
Page 30 of 48 of this pdf
24-May-07
If your spouse, civil partner or the person who
looks after children or qualifying young
persons for you works for an employer
Is your spouse, civil partner or
the person who looks after
children or qualifying young
persons for you, working for an
employer?
Employer 1
Please go to Part 13.
No
Yes
Please tell us about each employer.
Employer’s name and address
Payroll, staff or other reference
number
Please provide their payslips that cover the previous 5 weeks.
You must remember to provide all the documents we ask for.
If you do not, benefit you can get because of this claim may
be delayed.
Their weekly earnings after
income tax and National
Insurance (NI) contributions are
taken off.
Include
l earnings or fees as a director
l maternity pay
l holiday pay
l bonus payments
l regular tips
l Statutory Adoption Pay (SAP)
l Statutory Maternity Pay (SMP)
l Statutory Paternity Pay (SPP)
l Statutory Sick Pay (SSP).
Please tell us about any items
or services the employer
provides.
For example, special clothing.
Please give details of the
weekly amount of any expenses
connected with their work.
Do not include travelling expenses
to and from their place of work.
Is payment of Working Tax
Credit included in the
earnings?
Phone number
Fax number
Postcode
Code Number
Code Number
£ a week
£ a week
No
Yes
Please tell the weekly amount
Payslips received No Yes
For office use
23
Part 12
Page 31 of 48 of this pdf
24-May-07
If you need to tell us about more than 2 employers, use the space in Part 19.
Employer’s name and address
Payroll, staff or other reference
number
Please provide their payslips that cover the previous 5 weeks.
You must remember to provide all the documents we ask for.
If you do not, benefit you can get because of this claim may
be delayed.
Their weekly earnings after income
tax and National Insurance (NI)
contributions are taken off.
Include
l earnings or fees as a director
l maternity pay
l holiday pay
l bonus payments
l regular tips
l Statutory Adoption Pay (SAP)
l Statutory Maternity Pay (SMP)
l Statutory Paternity Pay (SPP)
l Statutory Sick Pay (SSP).
Please tell us about any items
or services the employer
provides.
For example, special clothing.
Please give details of the
weekly amount of any expenses
connected with their work.
Do not include travelling expenses
to and from their place of work.
Is payment of Working Tax
Credit included in the
earnings?
Phone number
Fax number
Employer 2
Postcode
Code Number
Code Number
£ a week
£ a week
No
Yes
Please tell the weekly amount
24
If your spouse, civil partner or the person who
looks after children or qualifying young persons
for you works for an employer
– continued
Part 12
Page 32 of 48 of this pdf
24-May-07
Is your spouse, civil partner
or the person who looks after
children or qualifying young
persons for you, off work
because of an illness or
disability, maternity leave or a
trade dispute?
Are they getting any payments
from their employer while they
are off work?
Include
l maternity pay
l Statutory Adoption Pay (SAP)
l Statutory Maternity Pay (SMP)
l Statutory Paternity Pay (SPP)
l Statutory Sick Pay (SSP).
Please go to
Part 13.
No
Yes
What date did they last work?
No
Yes
How much are they getting each week?
£ a week
//
25
If your spouse, civil partner or the person who
looks after children or qualifying young persons
for you works for an employer
– continued
Part 12
Page 33 of 48 of this pdf
24-May-07
26
Is your spouse, civil partner or
the person who looks after
children or qualifying young
persons for you, self-employed?
Tick Yes, if they own a business or
they have a share in a business.
This includes your business, if you
have one.
What is the name and address
of the business?
How much profit has the business
made for the last complete
business year?
By
profit, we mean any profit, gain
or other payments that have been
agreed for income tax purposes.
If you are self-employed, does
your spouse, civil partner or
someone who looks after
children or qualifying young
persons for you, help in your
business?
Do you pay your spouse, civil
partner or someone who looks
after children or qualifying young
persons for you, a wage?
Is a charge made for their
services against the profits from
your business for income tax
purposes?
No
Yes
Please tell us about this.
Postcode
£ a week
Please go to Part 14.
No
Yes
Please tell us about this.
No
Yes
What are their weekly earnings after income tax and
National Insurance (NI) contributions are taken off?
£ a week
No
Yes
What is the weekly charge?
£ a week
If your spouse, civil partner or the person who
looks after children or qualifying young
persons for you is self-employed
Part 13
Page 34 of 48 of this pdf
24-May-07
About other money coming in
Does your spouse, civil partner
or the person who looks after
children or qualifying young
persons for you, have any other
money coming in?
Do not tell us about other
benefits, occupational or personal
pensions. We will ask you about
these later in the form.
What is this money?
How much do they get each
week?
Please tell us the average
weekly amount if the money
is not the same each week.
Who pays the money?
What is their address?
Does your spouse, civil partner
or the person who looks after
children or qualifying young
persons for you, have any
boarders or lodgers?
Does this payment include
an amount for heating?
If you need to tell us about more than 3 boarders,
use the space in
Part 19.
How much does each boarder
or lodger pay each week?
Boarder 1
Boarder 2
Boarder 3
Please go to
Part 15.
No
Yes
Please tell us about this.
Postcode
£ a week
Please go to Part 15.
No
Yes
Please tell us about this.
£ a week
£ a week
£ a week
No
Yes
27
Part 14
Page 35 of 48 of this pdf
24-May-07
28
About occupational and personal pensions
Does your spouse, civil
partner or the person who
looks after children or
qualifying young persons for
you, get an occupational
pension or a personal
pension?
Name and address of the pension
payer
Phone number of the pension
payer
What is the pension reference
number?
How much pension do they get
after income tax is taken off?
How often is the pension paid?
What day or date are they
supposed to be paid?
For example, this could be every
Friday or the last working day of
each month.
Type of pension
Pension from an employer
Pension from a self-employed pension scheme
Personal pension
Important – please provide proof of their pension income,
this could be one of the following
l a letter of entitlement from their employer or insurance company who
pay the pension
l a payment advice notice from their pension provider
l a current wage slip showing details of their pension income
We need to see original documents, photocopies are not acceptable.
Failure to do so may affect your claim.
Pension 1
Please go to Part 16.
No
Yes
Please tell us about each pension.
Postcode
Code Number
£ a week
Proof of pension income received No Yes
For office use
Part 15
Page 36 of 48 of this pdf
24-May-07
About occupational and personal pensions – continued
Name and address of the pension
payer
Phone number of the pension
payer
What is the pension reference
number?
How much pension do they get
after income tax is taken off?
How often is the pension paid?
What day or date are they
supposed to be paid?
For example, this could be every
Friday or the last working day of
each month.
Type of pension
Pension from an employer
Pension from a self-employed pension scheme
Personal pension
Important – please provide proof of their pension income,
this could be one of the following
l a letter of entitlement from their employer or insurance company who
pay the pension
l a payment advice notice from their pension provider
l a current wage slip showing details of their pension income
We need to see original documents, photocopies are not acceptable.
Failure to do so may affect your claim.
Pension 2
Postcode
Code Number
£ a week
If you need to tell us about more than 2 pensions,
use the space in Part 19.
29
Part 15
Page 37 of 48 of this pdf
24-May-07
30
Do you want to claim extra
money for a person who does
not live with you and you
employ to look after children
or qualifying young persons
for you?
This could include an
organisation you may employ to
look after children or qualifying
young persons for you.
What is their name and address?
How much do you pay the
person or organisation who
looks after children or
qualifying young persons for
you each week?
Please give details of any
expenses you have in
connection with the care of
your children or qualifying
young persons.
What date do you want to claim
extra money from?
Please go to
Part 17.
No
Yes
Please tell us about this.
Postcode
£ a week
/ /
Part 16
Claiming extra money for someone who does
not live with you but you employ to look after
children or qualifying young persons for you
Page 38 of 48 of this pdf
24-May-07
About you and your partner
Part 1
About benefits and state pensions
Name of benefit
Who is the benefit paid to?
Benefit reference number
This is on letters about the
benefit.
If you need to tell us about more than 2 benefits, use the space in
Part 19.
Any money paid by the Department for Work and Pensions or
any other government department to
l your spouse,
l civil partner, or
l a person who looks after children or qualifying young
persons for you
may affect the amount of extra Incapacity Benefit that you can
get.
Money paid to another person for you or anyone you are
claiming for may also affect the amount of extra
Incapacity Benefit that you can get.
Please tell us about this money below. Include benefits, state
pensions or allowances from the Department for Work and
Pensions or any other government department. But do not
include any Child Benefit you have already told us about on
this form.
How much is paid each week?
Which office deals with the
benefit?
Benefit 1
£ a week
Name of benefit
Who is the benefit paid to?
Benefit reference number
This is on letters about the
benefit.
How much is paid each week?
Which office deals with the
benefit?
Benefit 2
£ a week
31
Part 17
Page 39 of 48 of this pdf
24-May-07
32
Making payments to you
Section 3 More information we need
We normally pay benefits directly into an account. This is the safest
way to pay you and lets you choose how and when you get your money.
You can use a bank, building society or other account provider. Most
accounts allow you to make savings on some of your bills by paying
them by Direct Debit. You may be able to use a cash machine, which will
usually mean you can get your money at any time of the day or night.
Most of these machines can be used for free, but some of them may
charge you to take your money out. If so, you will be warned by a
message on the screen. This will give you the opportunity to cancel your
transaction without being charged. There are arrangements with some
banks and building societies to let you collect cash from many of their
accounts over the counter at post offices.
A – Payment directly into an account
How you will be paid
Your benefit will be paid into the account every 2 weeks unless you choose
to be paid every 4 weeks or every 13 weeks.
If you choose to be paid every 2 weeks
The money will be paid into an account for you on the last bank working
day in each 2-week period.
If you choose to be paid every 4 weeks
The money will be paid into an account for you on the last bank working
day in 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 on the last bank working
day in 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.
Finding out how much is paid into the account
We will tell you when the first payment will be made and how much it is for.
Each payment, after the first one, should be for the same amount unless
there is a change in your circumstances. We will tell you whenever we
know there is going to be a change in the amount we pay into your
account.
You can check your benefit payments on your account statements. Your
statements will usually show your National Insurance (NI) number next to
payments that are from us. If you think your payment is wrong, get in touch
with the office that pays you.
Part 18
Page 40 of 48 of this pdf
24-May-07
Making payments to you – continued
A – Payment directly into an account – continued
Getting someone to collect your benefit
You may be able to get someone else to collect your benefit for you
regularly if you wish. For help with this please contact your bank,
building society or other account provider such as the Post Office® or a
Credit Union.
If not enough money is paid into the account
If we do not pay enough money into the account, we will make another
payment or add the money we owe you onto your next payment. We will
contact you to tell you what we are going to do.
Sometimes we may pay too much money into the
account and you may be overpaid
If this is because of the way the system works for payments directly into
an account, we have the right to recover any money you are not entitled
to. For example, you may give us information which means you are
entitled to less money but we may not be able to change the amount
already sent out. We will contact you first if we propose to recover any
money.
What to do now
To tell us about the account you want to use for your benefit,
go to Section B
or
if you do not already have a suitable account,
go to Section D.
B – About the account you want to use
Tick this box if you agree to be paid directly into an
account and understand the information in Section A
about being overpaid.
Please give your account details on the next page. You
must fill in ALL the boxes including the building society
roll or reference number if you have one.
You can find the account details on the cheque book,
passbook or statements. If you are not sure about the details,
ask the bank, building society, or other account provider.
33
Part 18
Page 41 of 48 of this pdf
24-May-07
34
Making payments to you – continued
B – About the account you want to use – continued
In your name
Whose name or names is the account in?
In the name of your partner
In the names of you and your partner
In the name of the person acting on
your behalf
In the names of you and the person
acting on your behalf.
Please tick one box
Please note:
l A Post Office® card account can only be in your name.
l We use partner to mean
– a person you are married to or a person you live
with as if you are married to them, or
– a civil partner or a person you live with as if you are
civil partners.
l By ticking the box for an account that includes the
name of the person acting on your behalf, you confirm
that you will authorise them to use the money in the
way you tell them, or you are an appointee acting on
behalf of the customer.
Full name of bank, building society or other account provider
Sort Code
– of the bank, building society or other account provider
Please tell us all six numbers, for example: 12-34-56.
Account number.
This is 7 to 10 numbers long.
Some building society accounts use a roll or reference number. The number is on the passbook.
The roll or reference number can contain letters and numbers and can be up to 18 characters long.
If you are not sure if the account has a roll or reference number, ask the building society.
More information if it is a building society account
You may be getting other benefits and entitlements that are not paid directly into an
account. To have them paid into this account, please tell us the names of the benefits or
entitlements.
Building society roll or reference number
What name or names is the account in?
Please write the name or names as they appear on the cheque book, passbook or statement.
Part 18
Page 42 of 48 of this pdf
24-May-07
Making payments to you – continued
D – If you did not complete Section B
Please read the notes below then tick Box 1 or Box 2.
If you have an account but you do not wish to use it, for example a joint
account, any bank or building society will help you open an account
that suits you better. Remember to ask whether their accounts allow you
to get your money from the Post Office®, if this is important to you.
l Basic bank accounts
If you have had problems opening a current account, or if you are
worried about being overdrawn, you could ask any bank or building
society about opening a basic bank account. These are available
from all major banks and offer free banking with no overdraft facility.
You can use these accounts to pay money in, pay bills automatically
and get cash out. Many basic bank accounts also allow you to get
cash from post offices.
l Other accounts
Alternatively, you can be paid into some Credit Union accounts or a
Post Office® card account. These accounts may have restrictions on
the services provided.
I intend to open an account.
I would like information about how I can be
paid by other means.
We will contact you about your payment options. If, in the meantime, you
want more information about opening an account, please contact us.
Complete the claim form and send it to us now.
Do not wait until you have opened an account.
Tick the box that applies to you.
Box 1
Any bank, building society or other account provider will help you open
an account. If you want to get your money at the Post Office®, check
that the account allows you to do this. If you want us to pay into an
account, tell us your account details as soon as you have them.
How often do you want your benefit to be paid?
Every 13 weeks
C – How often can I be paid?
Every 4 weeks Every 2 weeks
Box 2
35
Part 18
Page 43 of 48 of this pdf
24-May-07
36
Other information
Please tell us anything else you think we may need to know
to help us decide your claim.
Please give details of your
local Post Office®.
Postcode
Part 19
Page 44 of 48 of this pdf
24-May-07
Signing the form for someone else
I have Power of Attorney
for them.
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.
Please read page 2 of SC1 Notes.
I am signing this form on their behalf because
If the person does not know
you are signing this form for
them, please tell us why.
Your name
Your address
Daytime phone number
What is this number?
Please tick.
Please send us your power of attorney document or certified
copy with this claim form – remember to sign the
Declaration
section at Part 21.
I am a receiver for them
under a Court of Protection
Order, or in Scotland a tutor,
curator or guardian appointed
in terms of the law.
Please send us the relevant document or certified copy with
this claim form – remember to sign the Declaration section at
Part 21.
They cannot manage their
own affairs because of a
mental illness or a mental
disability.
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.
They are so ill or disabled
they find it impossible to
sign for themselves.
We will get in touch with you about this.
The Department for Work and
Pensions has already
appointed me to get their
benefits and to deal with
letters about their benefits.
We will send all letters about this claim directly to you.
Date of birth
National Insurance (NI)
number
Mr/Mrs/Miss/Ms
Postcode
Code Number
//
Home Work Mobile Fax
Letters Numbers Letter
37
Part 20
Page 45 of 48 of this pdf
24-May-07
38
Declaration
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, 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 doctor advising the Department
– any organisation with which the Department has a contract for
the provision of medical services
may ask any of the people or organisations mentioned on this
form for 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 doctor 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 in the future.
l I agree to my doctor, or any doctor who has been treating me,
being informed about the Secretary of State’s determination on
incapacity for work.
This is my claim for Incapacity Benefit.
Signature
Date
/ /
Part 21
Page 46 of 48 of this pdf
24-May-07
What to do now
What happens next
Help and advice
Part 24
Please make sure that you
l have answered all the questions on this form that apply to you,
and
l you have signed and dated this form, and
l check you are providing all the documents we have asked for.
Use the check list at Part 25.
This form and any documents we have asked you for are required by
Jobcentre Plus to process your claim.
Do not delay in making your claim to benefit. If you wait you could
lose money. Please note that benefit cannot be paid for a period more
than
3 months before the date we receive your claim.
If you can get Incapacity Benefit
we will write and tell you
l how much you can get
l more about the benefit.
Benefit you may get because of this claim will be paid more
quickly if you
l answer all the questions on this form that apply to you or the
person you are claiming an increase of benefit for, and
l provide all the documents we ask for.
If you cannot do this, get in touch with us straight away. If you do
not, you may lose benefit.
If you cannot get Incapacity Benefit
we will write and tell you the reason.
For information about your own claim
Get in touch with 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.
For general information about this benefit
Ring the Benefit Enquiry Line for people with disabilities. The number
is 0800 88 22 00. The person you speak to will be able to give you
general advice about the benefit. They can also tell you about other
organisations that may be able to help you.
If you have problems with hearing or speaking and use a textphone,
ring
0800 24 33 55. If you do not have your own textphone system,
they are available in some libraries and Citizens Advice Bureau.
For information about benefits and services visit our website at
www.dwp.gov.uk
39
Part 22
Part 23
Page 47 of 48 of this pdf
24-May-07
40
Check list
Please read the following list.
Tick the boxes to show which documents you are enclosing.
Your birth certificate
Spouse or civil partner’s birth
certificate
Marriage or civil partnership
certificate
Medical certificate
SSP1
SSP1(L)
P45
Proof of your pension income
Proof of pension income for your
spouse, civil partner or someone
looking after a child or qualifying
young person for you
Details of education, training or
apprenticeship
Payslip for your spouse, civil partner
or someone looking after children or
qualifying young persons for you
How we collect and use information
The information we collect about you and how we use it depends
mainly on the reason for your business with us, but we may use it
for any of the Department’s purposes, which include
l social security benefits and allowances
l child support
l employment and training
l private pensions policy, and
l retirement planning.
We may obtain information from others to check the information
you provide and to improve our services, and may give
information to other organisations as the law allows, for example
to safeguard against crime.
To find out more about how we use information, ask for leaflet
GL33 DWP and Your Personal Information at any of our offices, or
visit our website www.dwp.gov.uk/privacy.asp
Part 25
Part 26
Page 48 of 48 of this pdf
24-May-07
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