Fillable obseeker's Allowance Claim form J (Northern Ireland Public Sector)

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obseeker's Allowance Claim form J (Northern Ireland Public Sector)

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The obseeker's Allowance Claim form J (Northern Ireland Public Sector) form is 6 pages long and contains:

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J
obseeker's Allowance Claim form
Department for Communities Privacy Notice
UCJSA1
How DfC collects and uses information
The information the Department for Communities (DfC) collects from and about you depends
mainly on the reason for your business with us.
We will use information about you for all of the Department’s purposes, which include:
• The payment of social security benefits, grant loans and pensions;
• Child Maintenance;
• Employment and Training;
• Investigation of offences relating to social security;
• Social Security Research and Statistics.
DfC uses information to deal with enquiries and complaints, to provide DfC services, to protect
public funds, and to conduct research and produce statistics to monitor and improve our services.
We will obtain information about you as the law allows from other organisations to check the
information you give to us, protect public funds, and to improve our services.
DfC also shares information with other organisations as the law allows, for example to protect
against crime, and with HM Revenue and Customs.
DfC uses external suppliers to help deliver some services. We also use technology to make
decisions and improve our services. We will only ask you for information about your health when
this is needed for a benefit or service you are using. We will keep your information secure, and
make sure nobody has access to it who shouldn’t.
Please look at the DfC Privacy Notice on https://www.communities-ni.gov.uk/dfc-privacy-
notices to find out more about:
• your information rights;
• how to request a copy of your information;
• DfC’s data controller details and other data protection information;
• how long DfC will keep your data for; and
• more detail about how DfC uses personal information.
Page 1 of 7
Version 02/20
Any information that we ask you for is necessary to enable DfC to carry out its official duties.
The legal basis for the request is GDPR Article 6(1)(e) and Article 9(2)(b) for special category
information.
Part 1
Initial date of c
ontact
Part 2 About you
3
Surname
4
Other name(s)
5
Any other surname(s) you've been known by
6
Title (Mr, Mrs, Miss, Ms or other)
7
Date of birth
8
Your address
Postcode:
9
Would y
ou like us to send your post to a
different address?
Yes
No go to Question 12
10
Postcode:
11
Home phone number
M
obile phone
number
Daytime
phone
number
(if
different)
12
Relationship status
13
Are you widowed or a surviving civil partner?
Yes
No – go to Question 16
14
Date your husband, wife or civil partner died
15
Have you been on Jury Service in the last 12
weeks?
Yes
No - go to Question 18
16
Dates of your Jury Service
Please bring to your interview the letter you were given
by the court when your jury service ended. This will tell
us how long you were on jury service.
From
To
17
Have you been a student or been on any
government or vocational (work-related) training
scheme during the last 4 years?
Yes
No – go to question 25
18
Was
it education or
training?
Education
Training
19
Name
of c
ourse or training
programme
20
Page 2 of 7
National Insurance (NI) number
What address would you like us to send
your post to?
Where was the course or training programme held?
2
1
21
What date do you want to claim Jobseeker's Allowance
from?
If the dates in questions 1 and 2 differ, complete JSA5
UCJSA1
select...
select...
23
Number of hours per week
Start date
and OFFICIAL end date of the
course of education or training
From
To
Part 3 Work
24
Are you working at the moment?
Yes
26
Employer's name
27
Who should we contact about this employment?
(for example Personnel Department)
28
Employer's address
Postcode:
29
Employer's telephone number
30
What is y
our job?
31
Your usual occupation
32
A
re you self-employed or a
Company Director?
Yes (If JSA only consider issuing B16)
No
33
If you have one what is your staff or payroll number?
34
How many hours a week do you normally work on
average?
36
Are you paid
for this work?
Yes
No
37
How m
uch are you being
paid?
every
38
39 Is the work you
do voluntary?
Yes
No
Can you choose whether
you are paid or not?
Yes
No
Part 4
Previous
employment
40
Have you had a job that ended in the last 6 months?
Yes
No go to Question 59
41
Dates y
ou worked for this employer
42
Why did this job end?
43
Employer's name
47
Who should we contact about this employment? (for
example Personnel Department)
45
Employer's
address
Postcode:
46
Employer's phone number
49
What was your job?
50
51
Have you received, or do you expect to receive,
any payments because of the job that ended in the
last 6 months?
Yes
No
53
Who made this payment? Or who do you
expect to make this payment?
54
Were you self-employed or a Company Director?
UCJSA1
Page 3 of 7
Clock or payroll number
Yes
No go to question 41
25
Date the work started
Please bring the last 5 payslips to your interview.
55
£
22
Are you getting or did you get any funding in relation to
your studies?
Yes - If 'yes' please fill in forms JSA567S and ST1 we gave you
No
What site or department did you work in?
35
52
What site or department did you work in?
N
o
How frequently where you paid
From
To
Weekly
fortnightly 4 weekly
monthly
What date did your employer pay up to?
44 Amount
48
Date
Employee reference number
56
Have you got your P45?
Yes
57
If not, ar
e you expecting to receive your P45 in the
next 2 weeks?
58
Have
y
ou worked or claimed benefit outside the
United Kingdom in the last 4 years?
Yes consider completion of form CF(N)982A(NI) & BF627
No go to Question 70
59
Did you work or claim benefit in the
European Economic Area?
60
Which country or countries did you work or claim
benefit in?
61
Wer
e y
ou employed
by
a
foreign
employer?
62
Dates you worked?
From
To
63
Wer
e you
employed by a UK employer?
64
Dates you worked?
From
To
65
Were you self-employed?
66
Dates you worked?
From
To
67
Did you claim a UK benefit abroad?
68
Dates you c
laimed a UK benefit?
From
To
Part 5 About pensions
69
Do y
ou receive a pension or annuity?
Yes please bring proof of pension to your
interview No Go to Question 81
70
When
did the pension or annuity start?
71
How
much pension or annuity are you paid?
72
Does
your pension or annuity
increase
periodically?
73
How often
do
your pension
or
annuity
payments increase?
74
When do your pension or annuity
payments increase?
75
Name of y
our pension or annuity provider
76
Address o
f your pension or annuity provider
Postcode:
Do you expect to start receiving a pension or
annuity in the next 3 years?
Yes
No go to Part 6
When does the pension or annuity start?
How much pension or annuity do you expect
to be paid?
UCJSA1
Page 4 of 7
No
Yes
No
Yes
No
Yes
No
Yes
No
Y
es
No
Y
es
No
Yes
No
please bring this to your interview or provide when it is received
Pension or policy reference number
How much is the pension before any deductions?
How much is the pension after any deductions?
We mean deductions like income tax, for example.
every
every
77
78
79
80
81
82
83
every
£
£
£
select...
When should the pension or annuity have started?
How m
uch pension or annuity should you
have been paid?
every
Name
of your
pension or annuity provider
Address of your pension or annuity provider
Postcode:
Many banks and building societies will let you collect your money at the Post Office.
We will tell you when we make the first payment and how much it will be for.
We will tell you if the amount we pay into the account is going to change.
Finding out how much we have paid into the account
You can check your payments on account statements. The statements may show your National Insurance (NI) number next
to any payments we have made. If you think a payment is wrong, get in touch with the office that pays you straight away.
If we pay you too much money
We have the right to take back any money we pay that you are not entitled to. We may have paid you money you were not
entitled to because of the way the payment system works.
For example, you may give us some information which means you are entitled to less money. Sometimes we may not be
able to change the amount we have already paid you. This means we will have paid you money that you are not entitled to.
We will contact you before we take back any money.
Please tell us your account details below.
It is very important that you fill in all the boxes correctly, including the building society roll number 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.
UCJSA1
Page 5 of 7
Part 7 About the account you want to use
Name of the account holder
Please write the name of the account holder exactly as it is shown on the cheque book or account 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.
Part 6 How we pay you
We pay money directly into your bank account.
Do you have a pension or annuity that you could be
paid now, but have decided not to take?
Y
es
No
Address o
f your pension or annuity provider
Postcode:
Name
of your pension or annuity provider
84
85
8
6
89
90
91
£
8
7
If 'Yes', why have you chosen not to take it?
88
Part 9 Other information
Part 10 Claimant declaration
Before you sign the statement, please read the Declaration below.
I understand that:
•
If I knowingly give information that is incorrect or incomplete, my benefit may be stopped and I may be
liable for prosecution or other action.
•
I must promptly tell the office that pays my benefit of anything that may affect my entitlement to, or the
amount of, that benefit.
•
The information I have provided will be used to process my claim for Jobseeker's Allowance and may be used to decide my
entitlement to other benefits. Some of the information may be checked with other sources.
•
Any information may be used for other purposes relating to the work of the Department for Communities.
Some information may be given to other government bodies as permitted by law.
•
The informati
on I have give
n on this
for
m is
correct
an
d complet
e as
far
as
I
know
and believe.
Under sections
105(A) and 106(1A)
of
t
he Social
Security
Administration
(NI)
Act
1992
(c.8)
it
is
an
offence
to fail
t
o
notify
a
change of
circumstances
promptly.
Failure to tell us about a change in your circumstances promptly may result in action being taken against you.
This is my claim for Jobseeker's Allowance.
(Tick as appropriate)
The answers I have given to the questions on this form have been read back to me by the Interviewing Officer.
I agree they are correct and complete as far as I know and believe.
Signature
Date
Interviewing Officer’s Signature
UCJSA1
Page 6 of 7
Date
Part 8 Notified amendments
Have any of the details given originally
changed?
Yes
No
Which answers have been changed?
Details of change:
I declare that:
Office Code
I have read and understood the statement. The answers I have given to the questions on this form are correct and
complete as far as I know and believe.
PAGE 7 TO BE COMPLETED IN LOCAL OFFICE AND ID VERIFIED
UCJSA1
Page 7 of 7
For Official Use Only
Verification of ID
Yes
No
BWE day
First BWE date
Cycle
Sought Occupation
Usual Occupation
JSA567S issued
Claimant
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No
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obseeker's Allowance Claim form J (Northern Ireland Public Sector)

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Completed 5 January 2021

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