R40(M) PAGE 4
Declaration – Please make sure that you have read the R40 Notes at section 12.2 before signing
Blind Person's Allowance
If you are registered blind (severely sight impaired)
with a local authority, or other register, put 'X' in the box
Please also consider box 10.6 below
Enter the name of the local authority, or other register
(or 'Scotland' or 'Northern Ireland', as appropriate)
9.29.1
Please sign and date this form and then write your full name (in capital letters) in the space provided
The information I have given on this form is correct and complete to the best of my knowledge.
Signature Date
Name and title in capital letters
12.1
If you have signed on behalf of someone else, enter the
capacity, for example, parent, executor, receiver, attorney
Tick this box if you do not need a claim form in future
12.2
12.3
If you would like the payable order to go to your
UK bank, building society or any other nominee,
please enter in full the name, address and postcode
If your nominee is your adviser, enter their reference
Branch sort code
Account number
Name of account holder
Bank or building society roll or reference number, if you
have one
11.2
11.5
11.4
11.3
11.1
— —
11.6
Repayment instructions
If the payable order is to be sent to your bank or building
society, fill in boxes 11.1, 11.3, 11.4, 11.5 and 11.6, if applicable
To claim the full allowance, enter your spouse’s or civil
partner’s full name
If, as a couple, you have already asked us to give all of
the minimum amount to your spouse or civil partner,
put ‘X’ in the box
If you’ve already agreed that half of the minimum amount
is to go to your spouse or civil partner, put ‘X’ in the box
Your spouse’s or civil partner’s date of birth if older than
you and you filled in boxes 10.1, 10.2 or 10.3
DD MM YYYY
Enter the date of the marriage or civil partnership
DD MM YYYY
Any unused Married Couple’s, or Blind Person's Allowance
can be transferred from one spouse or civil partner to the
other – if you want us to send you a form to do this,
put ‘X’ in the box or you can download it from
www.hmrc.gov.uk/forms/575-t-man.pdf and attach it to
this claim form.
10.6
10.5
10.4
10.3
10.2
10.1
Married Couple's Allowance
This allowance is only due if you, or your spouse or civil partner, were born before 6 April 1935. Read page 11 of the Notes.
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