Fillable i Attendance Allowance for people of State Pension (Cabinet Office)

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i Attendance Allowance for people of State Pension (Cabinet Office)

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National Insurance number2
1
Please tell us your personal details. If you are filling in this form for someone else, tell
us about them, not you.
About you
3
The full address where you live
Sex
5
Date of birth (day/month/year)
4
What is your nationality?7
Surname or family name
All other names in full
Title
For example, Mr, Mrs, Miss, Ms
Please see question 7 in
the notes booklet
AA1 December 2020
Attendance Allowance
for people of State Pension age
or over
Letters Numbers Letter
Male Female
Postcode
i
Before you fill in this form, read page 3 of the notes
booklet that came with this form.
Mobile phone number,
if different
Daytime phone number
Please include the dialling code.
6
If you have speech or hearing difficulties and want us to contact you
by textphone, please tick this box.
Textphone number
If you are a Swiss or European Economic Area
(EEA) national please complete the Swiss or EEA
national additional question insert.
Please tell us when you went abroad.
Have you been abroad for more than 4 weeks at a time in the last 3 years?
Abroad means out of Great Britain.
9
Tell us where you went.
Tell us why you went.
If you have been abroad more than once in the last 3 years, please tell us the dates you
went, where you went and why you went at question 50 Extra information.
From To
Do you normally live in Great Britain?
Great Britain is England, Scotland and Wales.
8
About you continued
If you live in Wales and would like us to contact you in Welsh in future,
tick this box.
/ /
i
For more information please read page 7 of the notes.
Please continue below.Yes No Go to question 9.
Please continue below.Yes No Go to question 10.
2
Getting other benefits from a European Economic Area (EEA) state or
Switzerland
10
Are you, your wife, husband or civil partner getting any pensions or benefits from an
EEA state or Switzerland?
Go to question 11. We will contact you about this.No Yes
We will contact you about this.
Don’t know
Working or paying insurance in an EEA state or Switzerland
11
Are you, your wife, husband or civil partner working in or paying insurance to an EEA state or
Switzerland? By insurance we mean connected to work, like UK National Insurance.
Go to question 12.
We will contact you about this. No Yes
We will contact you about this.
Don’t know
About you continued
3
Signing the form for someone else
• you’ve already been legally appointed to receive and deal with their benefits.
That is, you’re a benefit appointee, a deputy or hold a Power of Attorney, or
• the person you’re claiming for is too ill or disabled to claim for themselves and
you want to be appointed to receive and deal with their benefits, or
• you’re completing this form in their absence and/or without their knowledge.
You can fill in the form for someone else, but they must still sign themselves unless:
13
Are you signing the form for someone else?
Continue below. Go to question 14.Yes No
Why are you signing the form for them? Please select one of the following.
I’m claiming for them under the special rules for terminally ill people.
You may wish to tell the person y
ou have claimed for that you have made
a claim to this benefit on their behalf. This is because we will send letters
about Attendance Allowance to them. There is no mention of terminal
illness or the special rules in our notifications.
12
The special rules are for people who have a progressive disease and are not expected
to live longer than another 6 months.
If you are claiming under the special rules you do not need to answer
questions20to 44.
Then please send this form to us with a DS1500 report. You can get the report
from your doctor or specialist.
If you have not got your DS1500 report by the time you have filled in the claim
form, send the claim form straight away. If you wait, you could lose money.
Please send the DS1500 report when you can.
Please make sure you sign the consent question 18 and the declaration
question 51
.
Special rules
If you are claiming under the special rules, tick this box.
i
You must read page 8 of the notes about special rules before you
complete this question.
Signing the form for someone else continued
Your full address
Your name
National Insurance number
Date of birth (day/month/year)
Daytime phone number,
including the dialling code
Letters Numbers Letter
Postcode
4
I’m a Deputy
I’m a Tutor (under Scottish law)
I’m an appointee, appointed by the
Department for Work and Pensions
I hold power of attorney
I’m a curator bonis or judicial factor
(under Scottish law)
I’m a Corporate Acting Body or
Corporate Appointee
Please tell us the name
of your organisation.
For example, an organisation appointed to act on behalf of the person the benefit is for,
such as a local authority or firm of solicitors.
Unless we’ve already seen this authority we’ll need to see it before we can
process the claim. Please send us your power of attorney or the relevant
documents with this claim. You can send the original or a certified copy.
Tick this box if:
I want to be appointed to act on their behalf.
• the person you’re claiming for is too ill or
disabled to claim for themselves and you
want to be appointed to handle their
benefit affairs, or
• you’re in the process of becoming a legally
appointed representative.
We’ll contact you about this.
About your illnesses or disabilities and the treatment
or help you receive
If you need more space to tell us about your illnesses or disabilities, please continue at
question 50 Extra information.
Please list separately details of your illnesses or disabilities in the table below.
By illnesses or disabilities we mean physical, sight, hearing or speech difficulty or
mental-health problems.
If you have a spare up-to-date printed prescription list, please send it in with this
form. If you send in your prescription list you do not need to tell us about your
medicines and dosage in the table below, but we still need to know your illness or
disability.
You can find the dosage on the label on your medicine.
By treatments we mean things like physiotherapy, speech therapy, occupational
therapy or visiting a day-care centre or a mental-health professional for counselling or
other treatments.
14
Name of illness
or disability
How long have
you had this
illness or
disability?
What medicines or
treatments (or both) have
you been prescribed for this
illness or disability?
What is the dosage
and how often do
you take each of
the medicines or
receive treatment?
Example
Alzheimer’s
Two years Aricept 10 milligrams (mg)
One tablet a day
Example
Kidney failure
One year Dialysis Two times a week
Example
Partially sighted About 10 years None None
5
Apart from your GP, in the last 12 months have you seen anyone about your illnesses
or disabilities?
For example, a hospital doctor or consultant, district or specialist nurse, community
psychiatric nurse, occupational therapist, physiotherapist, audiologist or social worker.
15
About your illnesses or disabilities and the treatment
or help you receive
continued
Please continue below.Yes No Go to question 16.
Postcode
Their name (Mr, Mrs, Miss, Ms, Dr)
Their profession or specialist area
The full address where you
see them
For example, the address of
the health centre or hospital
Their phone number,
including the dialling code
Your hospital record number
You can find this on your
appointment card or letter.
Which of your illnesses or
disabilities do you see them
about?
How often do you usually see
them because of your
illnesses or disabilities?
When did you last see
them because of your
illnesses or disabilities?
If you have seen more than one professional, please tell us their contact details,
whatthey treat you for and when you last saw them at question 50 Extra information.
6
Their name
About your illnesses or disabilities and the treatment
or help you receive
continued
Does anyone else help you because of your illnesses or disabilities?
For example, a carer, support worker, nurse, friend, neighbour or family member.
17
16
Their name
If you do not know your GP’s name,
please give the name of the
surgery or health centre.
Their relationship to you
How often do you see them?
If more than one person helps you, please tell us their name and how they help you at
question 50 Extra information.
About your GP
What help do you get
from them?
Their phone number,
including the dialling code
Please continue below.Yes No Go to question 17.
Their full address
Their full address
Their phone number,
including the dialling code
When did you last see
them because of your
illnesses or disabilities?
Postcode
The GP only gives details of medical fact, they don’t decide if you can get
Attendance Allowance.
Postcode
7
18
About your illnesses or disabilities and the treatment or
help you receive
continued
8
Consent
Please make sure you also sign and date the declaration at question 51.
Signature
Yes No
Date
We may want to contact your GP, or the people or organisations involved with you,
for information about your claim. This may include medical information. You do not
have to agree to us contacting these people or organisations, but if you don’t agree,
we may be unable to make sure you are entitled to the benefit you are claiming.
We, or any health care professional working for an organisation approved by the
Secretary of State, may ask any person or organisation to give them or us any
information, including medical information, which we need to deal with:
• this claim for benefit, or
• any appeal or other request to reconsider a decision about this claim.
Please tick one of the consent options then sign and date below.
I agree to you contacting the people or organisations described in the
statement above.
/ /
i
For more information please read page 9 of the notes
19
Do you have any reports about your illnesses or disabilities?
These may be from a person who treats you, for example, an occupational therapist,
hospital doctor or counsellor. It may be an assessment report, a care plan or
something like this.
Do not worry if you do not have any reports. Just send in your claim form.
If you are claiming under the special rules, please go to question 45.
You do not have to answer any more questions until then.
you have one.
Yes
Please send us a copy if
No Go to question 20.
Please remember to sign and date the form after printing.
About your illnesses or disabilities and the treatment or
help you receive
continued
Have you had any tests for your illnesses or disabilities?
For example, a peak flow, a treadmill exercise, a hearing or sight test or something else.
21
Date and type of test Results
Example
December 2014 treadmill test
Four minutes (stage 2)
Are you on a waiting list for surgery?
The date you were put
on the waiting list
What surgery are you going to
have?
When is the surgery
planned for, if you
know this?
Example
13 December 2014
Operation to replace my right hip 1 December 2015
20
Tell us about this in the
table below.
Yes No Go to question 21.
Tell us about these in
the table below.
Yes No Go to question 22.
9
What type of accommodation do you live in?22
For example, you may live in a house, bungalow, flat, supported housing,
residential care home, nursing home or somewhere else.
Aids and
adaptations
How does this help you? What difficulty do you have
using this aid or
adaptation?
Example
Magnifier Helps me to see the print in
the newspaper.
None
Example
Stairlift I can get up and down
stairs
I need help to get in and out
of the chair.
About your illnesses or disabilities and the treatment or
help you receive
continued
25
If you need more space to tell us about your aids or adaptations, please continue at
question 50 Extra information.
Please list any aids or adaptations you use.
Put a tick in the second box against those that have been prescribed by a health care
professional, for example, an occupational therapist.
If you have difficulty using any aids or adaptations or you need help from another person
to use them, tell us in the table below.
23
24
Where is there a toilet in your home?
Upstairs Downstairs Other
Tell us where.
Where do you sleep in your home?
Upstairs Downstairs Other
Tell us where.
i
For more information please read page 9 of the notes.
10
Your care needs during the day
During the day includes the evening. Care needs during the night are covered later.
By care needs we mean help or supervision, due to an illness or disability, with:
• everyday tasks like getting in and out of bed, dressing, washing
• taking part in certain hobbies, interests, social or religious activities, or
• communication.
Help means physical help, guidance or encouragement from someone else so you can do the task.
Use the tick boxes to tell us about the difficulty you have or the help you usually need.
Usually means most of the time.
It is important that you tell us about the difficulty you have or the help you need, whether
you get the help or not.
Do you usually have difficulty or do you need help getting out of bed in the morning
or getting into bed at night?
27
i
For more information about care and supervision see page 5 of the notes.
Please tick the boxes
that apply to you.
Yes No Go to question 28.
I have difficulty:
• getting into bed
• getting out of bed
I have difficulty concentrating or
motivating myself and need:
• encouraging to get out of bed in
the morning
• encouraging to go to bed at night
11
When your care needs started
Normally, you can only get Attendance Allowance if you have had difficulty or needed
help for 6 months.
Please tell us the date your care needs started.
If you cannot remember the exact date, tell us
roughly when this was.
Care needs
I need help:
• getting into bed
• getting out of bed
Help with your care needs during the day
26
Help with your care needs during the day continued
Do you usually have difficulty or do you need help with your toilet needs?
This means things like getting to the toilet, or using the toilet, commode, bedpan or bottle.
It also means using or changing incontinence aids, or a catheter or cleaning yourself.
28
For example
If you need help to get to and use the toilet four times a day, you would fill in the
boxes as shown below.
I have difficulty:
• with my toilet needs
How often each day?
4
Please continue below. No Go to question 29.
12
Yes
Please tell us what help you need and how often you need this help.
Is there anything else you want to tell us about the difficulty you have or the help
y
ou need getting in or out of bed?
For example, you may go back to bed during the day or stay in bed all day.
Tell us in the box below.Yes No Go to question 28.
How often each day?
How often each day?
I have difficulty:
• with my toilet needs
• with my incontinence needs
I have difficulty concentrating or
motivating myself and need:
• encouraging with my toilet needs
• encouraging with my incontinence needs
How often each day?I need help:
• with my toilet needs
• with my incontinence needs
Do you usually have difficulty or do you need help with washing, bathing, showering
or looking after your appearance?
This means things like getting into or out of the bath or shower, checking your
appearance or looking after your personal hygiene. Personal hygiene includes things like
cleaning your teeth, washing your hair, shaving or something like this.
29
Please tell us what help you need and how often you need this help.
Help with your care needs during the day continued
Please continue below. No Go to question 30.
• washing and drying myself or looking
after my personal hygiene
• using a shower
How often each day?I have difficulty:
• looking after my appearance
• getting in and out of the bath
13
Yes
Is there anything else you want to tell us about the difficulty you have or the help you
need with your toilet needs?
Tell us in the box below.
Yes No Go to question 29.
• washing and drying myself or looking
after my personal hygiene
• using a shower
How often each day?I need help:
• looking aft
er m
y appear
ance
•
getting in and out of the bath
Do you usually have difficulty or do you need help with dressing or undressing? 30
Help with your care needs during the day (continued)
Please tell us what help you need and how often you need this help.
Please continue below.
No Go to question 31.
• with choosing the appropriate clothes
How often each day?I have difficulty:
• with putting on or fastening clothes
or footwear
• with taking off clothes or footwear
14
Yes
Is there anything else you want to tell us about the difficulty you have or the
help you need washing, bathing, showering or looking after your appearance or
personal hygiene?
Tell us in the box below.
Yes No Go to question 30.
How often each day?
I have difficulty concentrating or
motivating myself and need:
• encouraging to look after my appearance
• encouraging or reminding about washing,
bathing, showering, drying or looking after
my personal hygiene
• with choosing the appropriate clothes
How often each day?I need help:
• with putting on or fastening clothes
or footwear
• with taking off clothes or footwear
Help with your care needs during the day continued
Do you usually have difficulty or do you need help with moving around indoors?
By indoors we mean anywhere inside, not just the place where you live.
31
Please tick the boxes
that apply to you.
No Go to question 32.
• getting in or out of a chair
• transferring to and from a wheelchair
I have difficulty:
• walking around indoors
• going up or down stairs
15
Yes
Is there anything else you want to tell us about the difficulty you have or the help you
need dressing or undressing?
For example, you may get breathless, feel pain or it may take you a long time.
Tell us in the box below.Yes No Go to question 31.
How often each day?
I have difficulty concentrating or
motivating myself and need:
• encouraging to get dressed or undressed
• reminding to change my clothes
• getting in or out of a chair
• transferring to and from a wheelchair
I need help:
• walking around indoors
• going up or down stairs
32
What happens when you fall or stumble?
Tell us why you fall or stumble and if you hurt yourself.
Do you fall or stumble because of your illnesses or disabilities?
For example, you may fall or stumble because you have weak muscles, stiff joints or
your knee gives way, or you may have problems with your sight, or you may faint,
feel dizzy, blackout or have a fit.
Help with your care needs during the day continued
Please continue below.Fall
No Go to question 33.
16
Is there anything else you want to tell us about the difficulty you have or the help
you need with moving around indoors?
For example, you may hold on to furniture to get about or it may take you a long time.
I have difficulty concentrating or
motivating myself and need:
• encouraging or reminding to move around indoors
Please continue below.
Stumble
Have you been referred to a Falls Clinic?
Yes No
Tell us in the box below.Yes No Go to question 32.
Help with your care needs during the day continued
Do you usually have difficulty or do you need help with cutting up food,
eating or drinking?
This means things like getting food or drink into your mouth or identifying
food on your plate.
33
Please continue below.Yes No Go to question 34.
How often each day?
I have difficulty concentrating or
motivating myself and need:
• encouraging or reminding to eat or drink
How often each day?I have difficulty:
• eating or drinking
• with cutting up food on my plate
17
How often do you fall or stumble?
Tell us roughly how many times you have
fallen or stumbled in the last month or year.
When did you last fall or stumble?
If you don’t know the exact date, tell us
roughly when this was.
times last month
times last year
Do you need help to get up after a fall?
Tell us if you have difficulty getting up after a fall and the help you need from someone else.
Tell us in the box below.Yes No
How often each day?I need help:
• eating or drinking
• with cutting up food on my plate
Help with your care needs during the day continued
Do you usually have difficulty or do you need help with taking your medicines or
with your medical treatment?
This means things like injections, an inhaler, eye drops, physiotherapy, oxygen
therapy, speech therapy, monitoring treatment, coping with side effects, and help
from mental-health services. It includes handling medicine and understanding
which medicines to take, how much to take and when to take them.
34
Please tell us what help you need and how often you need this help.
Please continue below.Yes No Go to question 35.
How often each day?
I have difficulty concentrating or
motivating myself and need:
• encouraging or reminding to take
my medication
How often each day?I have difficulty:
• taking my medication
• with my treatment or therapy
• encouraging or reminding about my
treatment or therapy
18
Is there anything else you want to tell us about the difficulty you have or the
help you need with cutting up food, eating or drinking?
Tell us in the box below.
Yes No Go to question 34.
How often each day?I need help:
• taking my medication
• with my treatment or therapy
Help with your care needs during the day continued
Do you usually need help from another person to communicate with other people?
For example, you may have a mental-health problem, learning disability, sight, hearing
or speech difficulty and need help to communicate. Please answer as if using your
normal aids, such as glasses or a hearing aid.
35
• concentrating or remembering things
I have difficulty:
• understanding people I do not know well
• being understood by people who do not
know me well
• reading letters, filling in forms, replying
to mail
• asking for help when I need it
• answering or using the phone
Please tick the boxes
that apply to you.
Yes No Go to question 36.
19
Is there anything else you want to tell us about the difficulty you have or the help you
need taking your medication or with medical treatment?
Tell us in the box below.Yes No Go to question 35.
Is there anything else you want to tell us about the difficulty you have or the help you
need from another person to communicate with other people?
For example, you use BSL (British Sign Language).
Tell us about your
communication needs
in the box below.
Yes No Go to question 36.
Help with your care needs during the day continued
• concentrating or remembering things
I need help:
• understanding people I do not know well
• being understood by people who do not
know me well
• reading letters, filling in forms, replying
to mail
• asking for help when I need it
• answering or using the phone
36
days
How many days a week do you have difficulty or need
help with the care needs you have told us about on
questions 26 to 34?
20
Do you usually need help from another person to actively take part in hobbies,
interests, social or religious activities?
We need this information because we can take into account the help you need or would
need to take part in these activities, as well as the other help you need during the day.
Help with your care needs during the day continued
What you do or would
like to do.
What help do you need or would you
need from another person to do this?
How often do
you or would
you do this?
Example
Listening to music
I cannot see and need help to find the disc
I want and put the disc in the player.
Four or five
times a week
Tell us about the activities and the help you need from another person at home.
Tell us about the activities and the help you need from another person when you go out.
What you do or would
like to do.
What help do you need or would you
need from another person to do this?
How often do
you or would
you do this?
Example
Swimming
When I get to the swimming pool I need
help to get changed, to dry myself and to
get in and out of the pool.
Three times a
week for half an
hour each time.
37
If you need some more space to tell us about your hobbies, interests, social or
religious activities please continue at question 50 Extra information.
Please continue below.Yes No Go to question 38.
21
38
Do you usually need someone to keep an eye on you?
For example, you may have a mental-health problem, learning disability, sight, hearing
or speech difficulty and need supervision.
Help with your care needs during the day continued
Is there anything else you want to tell us about the supervision you need
from another person?
How many days a week do you need someone to keep
an eye on you?
39
• I am at risk of neglecting myself.
• I am at risk of harming myself.
Please tell us why you need supervision.
• To prevent danger to myself or others.
• I am not aware of common dangers.
• To discourage antisocial or
aggressive behaviour.
• I may have fits, dizzy spells or blackouts.
• I may wander.
Please tick the boxes
that apply to you.
Yes No Go to question 40.
• I may get confused.
• I may hear voices or experience thoughts
that disrupt my thinking.
How long can you be safely left for
at a time?
Tell us in the box below.
Yes No Go to question 39.
days
22
Help with your care needs during the night
By night we mean when the household has closed down at the end of the day.
Do you usually have difficulty or need help during the night?
This means things like settling, getting into position to sleep, being propped up or getting
your bedclothes back on the bed if they fall off, getting to the toilet, using the toilet,
using a commode, bedpan or bottle, getting to and taking the tablets or medicines
prescribed for you and having any treatment or therapy.
40
Is there anything else you want to tell us about the difficulty you have or the help you
need during the night?
Please tell us what help you need, how often and
how long each time you need this help for.
Please continue below.
Yes No Go to question 42.
I have difficulty or need help:
• turning over or changing position in bed
• sleeping comfortably
How often
each night?
minutes
minutes
How long each time?
• with my toilet needs
• with my incontinence needs
minutes
minutes
• taking my medication
• with treatment or therapy
minutes
minutes
• encouraging or reminding about my toilet
or incontinence needs
• encouraging or reminding about
medication or medical treatment
minutes
minutes
I have difficulty concentrating or
motivating myself and need:
Tell us in the box below.
Yes No Go to question 41.
23
How often
each night?
How long each time?
1 2 3+
1 2 3+
Do you usually need someone to watch over you?
For example, you may have a mental-health problem, learning disability, sight, hearing or
speech difficulty and need another person to be awake to watch over you.
42
How many times a night does another person need to be
awake to watch over you?
minutes
Is there anything else you want to tell us about why you
need someone to watch over you?
Help with your care needs during the night continued
How many nights a week do you need someone to watch
over you?
43
Please tick the boxes
that apply to you.
Yes No Go to question 44.
How long on average does another person need to be awake
to watch over you at night?
• I am at risk of harming myself.
• I may wander.
Please tell us why you need watching over.
• To prevent danger to myself or others.
• I am not aware of common dangers.
• I may get confused.
• I may hear voices or experience thoughts
that disrupt my thinking.
• To discourage antisocial or
aggressive behaviour.
Tell us in the box below.
Yes No Go to question 43.
nights
24
How many nights a week do you have difficulty or need
help with your care needs?
41
nights
Help with your care needs
Please tell us anything else you think we should know about the difficulty you have or
the help you need.
If you need some more space to tell us about the help you need or the difficulty you have
with your care needs, please continue at question 50 Extra information.
44
25
About time spent in hospital, a care home or
a similar place
45
Are you in hospital, a care home or similar place now?
For example, a residential care home, nursing home, hospice or similiar place.
Please tell us the full name and
address of the place where you
are staying.
If you are in hospital, why did
you go into hospital?
Postcode
Does a local authority, health authority, education authority or a
government department give you, or the place where you stay,
any money towards the costs of your stay?
Please tell us the full name and
address of the place where you
were staying.
If “Yes”, which authority or
government department
pays?
Have you come out of hospital, a care home or similar place in the past 6 weeks?
46
If you have been in hospital, why
did you go into hospital?
i
For more information please read page 10 of the notes.
Tell us when you went in.Yes No Go to question 46.
Yes No
T
ell us when you went in.
Yes No Go to question 47.
Go to question 46.
Tell us when you came out.
Postcode
26
Constant Attendance Allowance
47
Please tick the box if you are getting or waiting to hear about:
• War Pension Constant Attendance Allowance
Constant Attendance Allowance
How we pay you
48
• Industrial Injuries Disablement Benefit Constant Attendance Allowance
i
Please read page 10 of the notes before you fill in this page.
Please tell us the account details below.
It’s 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.
27
Name of the account holder
Please write the name of the
account holder exactly as it is shown
on the chequebook or statement.
Full name of bank or
building society
Sort code
Please tell us all 6 numbers,
for example: 12-34-56.
Account number
Most account numbers are 8 numbers
long. If your account number has
fewer than 10 numbers, please fill in
the numbers from the left.
Building society roll or reference number
If you are using a building society account you may need to tell us a roll or reference
number. This may be made up of letters and numbers, and may be up to
18characters long. If you are not sure if the account has a roll or reference number,
ask the building society.
You may get other benefits and
entitlements we do not pay into
an account. If you want us to pay
them into the account above,
please tick this box.
How we pay you
If you do want this statement to be filled in, the best person to do it is the one who is
most involved with your treatment or care. This may be someone you have already told
us about on this form.
If you are signing this form on behalf of the disabled person, please get someone else to
fill in this section.
Your full name
Date
Tell us your job, profession or relationship to the person this form is about.
Please tell us what their illnesses and disabilities are,
and ho
w they are affected by them.
How often do you see the person this form is about?
49
Statement from someone who knows you
/ /
Please note, this statement does not have to be filled in.
Postcode
Daytime phone number,
where we can contact you or
leave a message
Your full address
Your signature
28
Please remember to sign and date the form after printing.
Continue on a separate piece of paper, if necessary. Remember to write your name and
National Insurance number at the top of each page.
Please tell us anything else you think we should know about your claim.
50
Extra information
29
Declaration
We cannot pay any benefit until you have signed the declaration, and returned the
form to us. Please return the signed form straight away.
By submitting this claim you agree that the information you've given is complete
and correct; while you're receiving Attendance Allowance, you'll report changes to
your circumstances straight away by calling 0800 731 0122. If you give wrong or
incomplete information, or you don’t report changes straightaway, you may:
• be prosecuted
• need to pay a financial penalty
• have your Attendance Allowance reduced
or stopped
• be paid too much Attendance Allowance
and have to pay the money back
If we pay you less than we should, we may
pay you the money that we owe you.
Date
Signature
Have you signed and dated the consent question 18 on this claim form?
51
Print your name here
/ /
i
For information about how we collect and use information and help and
advice about other benefits, see pages 10 and 11 of the notes.
30
i
For information about what happens next, see page 12 of the notes.
What happens next
Please list all the documents you are sending with this claim form below.
For example, a prescription list, a certificate of vision impairment, a medical report,
passport or a care plan.
Send the claim form and any reports, if you hold them, back to us in the envelope
we have sent you. It does not need a stamp. Send copies as we cannot return
them.
What to do now
31
52
Please check that you have filled in all the questions that apply to you or the person
you are claiming for. Failure to answer all the required questions may affect the time
taken to deal with your claim.
Make sure you have ticked the relevant box and
signed the consent at question 18.
Make sure that you ha
ve included full details for
anyone else you have seen at question 15.
Make sure you have signed the declaration at question 51.
Make sure that you have included full details of your GP at question 17.
Make sure that you have included full details for
anyone else who helps you at question 16.
Checklist
Make sure you have completed care needs start date at question 26.
Where to send the completed form
Please print off the completed form, sign and date the consent at question 18 and
declaration at question 51 then send the form and any supporting documents to:
Attendance Allowance Unit
Mail Handling Site A
Wolverhampton
WV98 2AD
Please return the completed claim form as soon as you can as we can only
consider paying benefit from the day we receive it.
For help or advice you can call the Attendance Allowance Service Centre
on 0800 731 0122.
Textphone: 0800 731 0317 for people who do not speak or hear clearly.
We cannot accept claim forms returned by email.
Help using this PDF claim form
You can save data typed into this PDF claim form if you use Adobe Reader.
This means that you do not have to fill the form in one session.
This form will only save if:
• the form is saved onto your computer, and
• opened in
a recent version of Adobe Reader
The form will not save in:
• versions of Acrobat Reader older than version XI
• other PDF readers, for example Preview on a Mac or Foxit on a PC
You can download Adobe Reader free of charge from the Adobe website.
If you are having technical difficulties:
• downloading the form
• navigating around the form, or
• printing the form
Please contact the DWP Online helpdesk.
Phone: 0800
169
0154
Email: dwponline.helpdesk@dwp.gsi.gov.uk
Opening hours
Monday to Friday: 8am - 6pm
Closed on weekends and 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.
Calls to 0800 numbers are free from landlines or mobiles.
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i Attendance Allowance for people of State Pension (Cabinet Office)

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Completed 22 March 2021

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