Attendance Allowance
for
people
aged
65
or
over
Please
fill
in
this
claim
form
and
send
it
back
to
us
as
soon
as
you
can.
We
can
only
consider
paying
benefit
from
the
date
we
receive
it.
If
you
want
help
filling
in
this
form
you
can
phone
the
Benefit
Enquiry
Line
(BEL)
or
contact
an
organisation
like
Citizens
Advice.
BEL
is
open
from
8.30am
to
6.30pm
Monday
to
Friday,
and
from
9am
to
1pm
on
Saturdays.
Phone
0800
88
22
00
If
you
have
speech
or
hearing
difficulties,
you
can
contact
us
using
a
textphone
on
0800
24
33
55
.
These
textphones
do
not
accept
texts
from
mobile
phones.
You
can
also
use
Typetalk.
We
can
send
you
a
claim
form
in
Braille
or
in
large
print.
Or,
BEL
can
arrange
to
fill
one
in
with
you
over
the
phone.
They
will
send
you
the
filledin
claim
form
in
Braille
or
in
large
print.
We
can
also
arrange
for
interpreters
if
you
phone
us
or
visit
us.
If
you
want
any
more
information
about
this,
please
phone
BEL.
Pleasekeepthispagewiththenotesaboutclaiming AttendanceAllowance.Youmayneeditafteryouhave senttheclaimformbacktous.
AA1ASeptember2008
Notes Save Previous page Next page Feedback
Read notes
Notes Save Previous page Next page Feedback
03-Mar-09
Things
to
get
together
before
you
fill
in
the
claim
form
Beforeyoufillintheclaimform,itwillbeusefultohavereadysome ofthethingslistedbelow.Donotworryifyoudonothaveallof them.
• YourNationalInsurancenumber. Youcanfindthisonyour
NationalInsurancenumbercard,lettersfromtheDepartmentfor Work andPensionsorpayslips.IfyoudonothaveaNational Insurancenumber, oryoudonotknowit,getintouchwith
JobcentrePlus.Theywillhelpyouapplyforortraceyournumber.
• ThenameofyourGPandtheaddressofyourGP’ssurgery.
• Detailsofyourmedicationoranuptodateprintedprescription listifyouhaveone.
• Detailsofanyoneyouhaveseenaboutyourillnessesor disabilitiesinthelast12months,apartfromyourGP.
• Yourhospitalrecordnumber(ifyouknowit).You canfindthis onyourappointmentcardorletter.
• Ifyouhavebeeninhospital,acarehomeorsimilarplace,the datesyouwentinandcameoutandthenameandaddressofthe placeyoustayed.
Youmayfindithelpfultokeeparecordofyourneeds.
i
Formoreinformationpleasereadpage6ofthenotes. Youdonothavetofillintheforminonego.Takeyourtimesothat youcandescribeallthehelpyouneed.How to fill in the claim form
Pleaseuseblackinktofillinthisform.Donotworryifyouare notsurehowtospellsomethingoryoumakeamistake.Ifyou wanttocorrectamistake,pleasecrossitoutwithapen donot usecorrectionfluid.
Pleaseticktheboxtoshow
youranswer, forexample: Yes
�
NoWhat happens next
Fillintheclaimformandpostitbacktous.
Writethedateyoupostyourclaimformtousinthisbox.
We willwritetoyoutotellyouthatwehavereceivedyourclaim form.Ifyoudonotgetthisletterwithintwoweeksofsendingyour claimformtous,pleasephoneuson08457123456.Ifyouhave speechorhearingdifficulties,youcancontactususingatextphone on08457224433.
PleasekeepthispagewiththenotesaboutclaimingAttendanceAllowance.Youmay needitafteryouhavesenttheclaimformbacktous.
Page 2 of 31 of this pdf
Save Previous page Next page Feedback
Notes
03-Mar-09
Save Previous page Next page Feedback
Attendance Allowance
for
people
aged
65
or
over
Please
fill
in
this
claim
form
and
send
it
back
to
us
as
soon
as
you
can.
We
can
only
consider
paying
benefit
from
the
date
we
receive
it.
About
you
Pleasetellusyourpersonaldetails.Ifyouarefillinginthisformforsomeoneelse,tell usaboutthem,notyourself.
1 Surnameorfamily name
Allother namesinfull
Title
Forexample,Mr,Mrs,Miss,Ms
2 NationalInsurance number
Letters Numbers Letter
4 Sex
3 Date ofbirth
(day/month/year)
Male Female
5 Address whereyoulive
Postcode
6 Daytimephonenumberwherewecancontactyouorleaveamessage.
Phonenumber,
includingthediallingcode
Ticktoshowhowyouwouldpreferustocontactyou.
Phone Fax
Mobilenumber
Textphone
Ourtextphoneservicedoesnotreceivemessagesfrommobilephones.
7 Whatis yournationality?
Forexample,British,Spanish,Turkish
1 AA1ASeptember2008
Page 3 of 31 of this pdf
Title
Save Previous page Next page Feedback
Notes
Save Previous page Next page Feedback
Notes
About
you (continued)
8 Doyou normallylivein GreatBritain?
GreatBritainisEngland,ScotlandandWales.
i
Formoreinformationpleasereadpage7ofthenotes.Yes Pleasecontinuebelow. No Gotoquestion9.
IfyouliveinWalesandwouldlikeustocontactyouinWelsh,tickthisbox.
9 Haveyoubeenabroadfor morethan atotal of 13weeksin the last52weeks?
AbroadmeansoutofGreatBritain.
Yes Pleasecontinuebelow. No Gotoquestion10.
Ifyouhavebeenabroadformorethan13weeksinthelast52weeks,pleasetellus whenyouwentabroad,whereyouwentandwhyyouwent.
From
Telluswhereyouwent.
To
Telluswhyyouwent.
Ifyouhavebeenabroadmorethanonceinthelast52weeks,pleasetellusthedates youwent,whereyouwentandwhyyouwentatquestion45Extrainformation.
10 Whattype ofaccommodation doyoulivein?
Forexample,youmayliveinahouse,bungalow,flat,supportedhousing,residential carehome,nursinghomeorsomewhereelse.
2
Page 4 of 31 of this pdf
Save Previous page Next page Feedback
Notes
03-Mar-09
Save Previous page Next page Feedback
Signing
the
form
for
someone
else
11 Signing the formfor someone else
Youcanfillinthisformforanotheradult,buttheymuststillsignitthemselves unlessoneormoreofthefollowingapply.Pleasetickalltherelevantboxes.
� Iholdapowerofattorneytoreceiveanddealwiththeirbenefitsfrom socialsecurity,or
� Iactasadeputyforthem,appointedbytheCourtofProtection,or
� InScotland,Iamajudicialfactor,guardian,tutororcuratorbonis appointedunderScottishlaw.
Sendustherelevantdocument(orcertifiedcopy)withthisclaimformand signthedeclarationontheirbehalf.Copiesmustbecertified,andsigned, as beingtrueandcompletebythecustomer,asolicitororastockbroker.
� IamanAppointee,appointedbytheDepartmentforWork andPensions (DWP),toreceiveanddealwiththeirbenefitsandtheirlettersfromsocial security.
WewillsendalllettersaboutAttendanceAllowancetoyou.
� Theycannotmanagetheiraffairsduetoamentalhealthproblemor learningdisability.
Wewillcontactyouaboutthis.Ifthecustomercannotmanagetheiraffairs theDWP mayappointyoutogettheirbenefitsandtodealwithletters fromsocialsecurity.
� Theyaresoillordisabledtheyfinditimpossibletosignforthemselves.
Wewillcontactyouaboutthis.
� Iamclaimingforthemunderthespecialrules.
You mustreadthenotesaboutspecialrulesonpage8ofthenotes before youtickthisboxandticktheboxatquestion17.
Ifthepersondoesnotknowyouaresigningthisformforthem,telluswhy.
i
Yourname
NationalInsurance number
Date ofbirth (day/month/year)
Youraddress
Letters Numbers Letter
Postcode
Daytimephonenumber,
includingthediallingcode
3
Page 5 of 31 of this pdf
Save Previous page Next page Feedback
Notes
03-Mar-09
Save Previous page Next page Feedback
About
your
illnesses
or
disabilities
and
the
treatment
or
help
you
receive
12 Please listseparately detailsofyour illnessesordisabilitiesin the tablebelow.
Byillnessesordisabilitieswemeanphysical,sight,hearingorspeechdifficultyor mentalhealthproblems.
Ifyouhaveaspareuptodateprintedprescriptionlist,pleasesenditinwiththis form. Ifyousendinyourprescriptionlistyoudonotneedtotellusaboutyour medicinesanddosageinthetablebelow.
Youcanfindthedosageonthelabelonyourmedicine.
Bytreatmentswemeanthingslikephysiotherapy,speechtherapy,occupational therapyorvisitingadaycarecentreoramentalhealthprofessionalfor
counsellingorothertreatments.
Nameofillness Howlonghave Whatmedicinesor Whatisthedosage
ordisability. youhadthis treatments(orboth)have andhowoftendo
illnessor youbeenprescribedfor youtakeeachof
disability? thisillnessordisability? themedicinesor receivetreatment?
Example Twoyears Aricept 10milligrams(mg)
Alzheimer’s Onetabletaday
Example Oneyear Dialysis Twotimesaweek
Kidneyfailure
Example About10years None None
Partiallysighted
If
atquestion45Extrainformation.
you need more space to tell us about your illnesses or disabilities, please continue
4
Save Previous page Next page Feedback
Notes
03-Mar-09
Save Previous page Next page Feedback
About
your
illnesses
or
disabilities
and
the
treatment
or
help
you
receive
(continued)
13 Apartfrom your GP,in the last12months,have youseenanyone about your
illnessesordisabilities?
Forexample,ahospitaldoctororconsultant,districtorspecialistnurse,community psychiatricnurse,occupationaltherapist,physiotherapist,audiologistorsocialworker.
Yes Pleasecontinuebelow. No Gotoquestion14.
Theirname(Mr,Mrs,Miss,Ms,Dr)
Theirprofessionorspecialistarea
Theaddresswhereyousee themforexample,theaddress ofthehealthcentreorhospital.
Postcode
Theirphonenumber, includingthediallingcode
Yourhospitalrecord number Youcanfindthisonyour appointmentcardorletter.
Whichofyourillnessesor disabilitiesdoyouseethem about?
Howoftendoyouusuallysee thembecauseofyourillnesses ordisabilities?
Whendidyoulastseethem becauseofyourillnesses ordisabilities?
Ifyouhaveseenmorethanoneprofessional,pleasetellustheircontactdetails,what theytreatyouforandwhenyoulastsawthematquestion45Extrainformation.
5
Title
Notes
Save Previous page Next page Feedback
Notes Save Previous page Next page Feedback
About
your
illnesses
or
disabilities
and
the
treatment
or
help
you
receive
(continued)
14 Does anyone elsehelpyoubecause ofyour illnessesordisabilities?
Forexample,acarer,supportworker, nurse,friend,neighbourorfamilymember.
Theirname
Yes Pleasecontinuebelow. No Gotoquestion15.
Theiraddress
Postcode
Theirphonenumber, includingthediallingcode
Whathelpdoyouget
fromthem?
Theirrelationshiptoyou
Howoftendoyouseethem?
Ifmorethanonepersonhelpsyou,pleasetellustheirnameandhowtheyhelpyouat question45Extrainformation.
15 About your GP
i
Formoreinformationpleasereadpage7ofthenotes. TheirnameIfyoudonotknowyourGP’s name,pleasegivethenameof thesurgeryorhealthcentre.
Theiraddress
6
Postcode
Theirphonenumber, includingthediallingcode
Whendidyoulastseethem becauseofyourillnesses ordisabilities?
Page 8 of 31 of this pdf
Notes
Save Previous page Next page Feedback
03-Mar-09
About
your
illnesses
or
disabilities
and
the
treatment
or
help
you
receive
(continued)
16 Consent
We maywanttocontactyourGP,orthepeopleororganisationsinvolvedwithyou, forinformationinrelationtoyourclaim.Thismayincludemedicalinformationin respectofyourclaim.Youdonothavetoagreetouscontactingthesepeopleor organisations,butifyoudonot,itmaymeanthatwecannotgetenough
informationtosatisfyourselvesthatyoumeettheconditionsofentitlementin respectofyourclaim.
TheDepartmentforWork andPensions,oranyhealthcareprofessionalproviding medicalservicesonbehalfofanorganisationapprovedbytheSecretaryofState, mayaskanypersonororganisationforanyinformation,includingmedical
information,whichweneedtodealwith: •thisclaimforbenefit,or
•anyappealorotherreconsiderationofadecisioninrelationtothisclaim, andthattheinformationmaybegiventothathealthcareprofessionalortothe Department.
Please tickoneofthe consent optionsthen signanddate below.
Iagreetoyoucontactingtherelevantpeopleor organisations,asinthestatementabove.
Idonotagreetoyoucontactingtherelevantpeople ororganisations,asinthestatementabove.
Signature Date
i
7 Pleasemakesureyoualsosignanddatethedeclarationquestion46.
17 Specialrules
Youmustreadpage8ofthenotesaboutspecialrulesbeforeyou ticktheboxbelow.
Thespecialrulesapplytopeoplewhohaveaprogressivediseaseandarenot expectedtolivelongerthansixmonths.
Ifyouarenotclaimingunderthespecialrulespleasegotoquestion18.
Ifyouareclaimingunderthespecialrules,tickthisbox.
Ifyouareclaimingunderthespecialrulespleasegotostraighttoquestion39. ThenpleasesendthisformtouswithaDS1500report.Youcangetthereport fromyourdoctororspecialist.
IfyouhavenotgotyourDS1500reportbythetimeyouhavefilledintheclaim form,sendtheclaimformstraightaway.Ifyouwait,youcouldlosemoney. PleasesendtheDS1500reportwhenyoucan.
Pleasemakesureyousigntheconsentaboveandthedeclarationquestion46.
Page 9 of 31 of this pdf
Please remember to sign and date the form after printing.
Notes
Save Previous page Next page Feedback
03-Mar-09
Save Previous page Next page Feedback
About
your
illnesses
or
disabilities
and
the
treatment
or
help
you
receive
(continued)
Ifyouareclaimingunderthespecialrules,pleasegotoquestion39.You donot havetoansweranymorequestionsuntilthen.
18 Doyou haveanyreports aboutyour illnessesordisabilities?
Thesemaybefromapersonwhotreatsyou,forexample,anoccupationaltherapist, hospitaldoctororcounsellor. Itmaybeanassessmentreport, acareplanor
somethinglikethis.
Pleasesendusacopyif youhaveone.
Yes No Gotoquestion19.
Donotworryifyoudonothaveanyreports.Justsendinyourclaimform.
19 Are youonawaiting list forsurgery?
Tellusaboutthisinthe tablebelow.
Yes No Gotoquestion20.
Thedateyouwereput Whatsurgeryareyougoingto Whenisthesurgery
onthewaitinglist have? plannedfor,ifyou
knowthis?
Example
1May2008 Operationtoreplacemyrighthip 1October2008
20 Haveyouhadanytests for yourillnessesordisabilities?
Forexample,apeakflow,atreadmillexercise,ahearingorsighttestorsomething else.
Tellusaboutthesein thetablebelow.
Yes No Gotoquestion21.
Dateandtypeoftest Results
Example
April2008treadmilltest Fourminutes(stage2)
8
Notes
Save Previous page Next page Feedback
03-Mar-09
About your illnesses or disabilities and the treatment or help
you receive (continued)
9 21 Where is there a toilet in your home?
Upstairs Downstairs Other
Tell us where.
Upstairs
22 Where do you sleep in your home?
Downstairs Other
Tell us where.
i
For more information please read page 9 of thenotes. Aids andadaptations
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.
If you need more space to tell us about your aids or adaptations, please continue at question 45Extra information.
23 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.
Notes
Save Previous page Next page Feedback
03-Mar-09
Your
care
needs
during
the
day
Duringthedayincludestheevening
Bycareneedswemeanhelporsupervision,duetoanillnessordisability,with: • everydaytaskslikegettinginandoutofbed,dressing,washing
• takingpartincertainhobbies,interests,socialorreligiousactivities,or • communication.
Helpmeansphysicalhelp,guidance orencouragementfromsomeoneelsesoyou candothetask.
Usethetickboxestotellusaboutthedifficultyyouhaveorthehelpyou usuallyneed.Usuallymeansmostofthetime.
Itisimportantthatyoutellusaboutthedifficultyyouhaveorthehelpyou need,whetheryougetthehelpornot.
i
Formoreinformationaboutcareandsupervisionseepage4 ofthenotes.24 Doyou usually havedifficultyor doyou needhelpgettingoutof bed inthe morningor gettingintobed at night?
Pleaseticktheboxesthat
No
Yes applytoyou. Gotoquestion25.
Ihavedifficultyorneedhelp:
• gettingintobed
• gettingoutofbed
Ihavedifficultyconcentratingor motivatingmyselfandneed:
• encouragingtogetoutofbedinthe morning
• encouragingtogotobedatnight
Isthereanythingelseyouwanttotellusaboutthedifficultyyouhaveorthehelp youneedgettinginoroutofbed?
Forexample,youmaygobacktobedduringthedayorstayinbedallday.
Yes Tellusintheboxbelow. No Gotoquestion25.
10
Page 12 of 31 of this pdf
03-Mar-09
Save Previous page Next page Feedback
Save Previous page Next page Feedback
Notes
Help
with
your
care
needs
during
the
day
(continued)
25 Doyouusually havedifficultyordoyouneedhelpwithyourtoilet needs?
Thismeansthingslikegettingtothetoilet,usingthetoilet,acommode,bedpanor bottle.Italsomeansusingorchanging incontinenceaids,acatheterorcleaning yourself.
Gotoquestion26.
Pleasetelluswhathelpyouneedandhowoftenyouneedthishelp.
Yes Pleasecontinuebelow. No
Ihavedifficultyorneedhelp:
• withmytoiletneeds
Forexample
Ifyouneedhelptogettoandusethetoiletfourtimesaday,youwouldfillinthe boxesasshownbelow.
Howoften?
4
times
a
day
Ihavedifficultyorneedhelp: Howoften?
• withmytoiletneeds
• withmyincontinenceneeds
Ihavedifficultyconcentratingor
motivatingmyselfandneed: Howoften?
• encouragingwithmytoiletneeds
• encouragingwithmyincontinence needs
Isthereanythingelseyouwanttotellusaboutthedifficultyyouhaveorthehelp youneedwithyourtoiletneeds?
Yes Tellusintheboxbelow. No Gotoquestion26.
11
Page 13 of 31 of this pdf
Notes
Save Previous page Next page Feedback
03-Mar-09
Help
with
your
care
needs
during
the
day
(continued)
26 Doyou usuallyhave difficultyordoyou needhelp with washing,bathing, showeringorlooking after yourappearance?
Thismeansthingslikegettingintooroutofthebathorshower, checkingyour appearanceorlookingafteryourpersonalhygieneincludingthingslikecleaning yourteeth,washingyourhair,shavingorsomethinglikethis.
Yes Pleasecontinuebelow. No Gotoquestion27.
Pleasetelluswhathelpyouneedandhowoftenyouneedthishelp.
Ihavedifficultyorneedhelp: Howoften?
• lookingaftermyappearance
• gettinginandoutofthebath
• washinganddryingmyselforlooking aftermypersonalhygiene
• usingashower
Ihavedifficultyconcentratingor motivatingmyselfandneed:
• encouragingtolookaftermy appearance
• encouragingorremindingabout washing,bathing,showering,drying orlookingaftermypersonalhygiene
Howoften?
Isthereanythingelseyouwanttotellusaboutthedifficultyyouhaveorthehelp youneedwashing,bathing,showeringorlookingafteryourappearance?
Tellusintheboxbelow. No Gotoquestion27.
12
Page 14 of 31 of this pdf
Notes Notes
Save Previous page Next page Feedback
03-Mar-09
Help
with
your
care
needs
during
the
day
(continued)
27 Doyou usuallyhave difficultyordoyou needhelp with dressingorundressing?
Yes Pleasecontinuebelow. No Gotoquestion28.
Pleasetelluswhathelpyouneedandhowoftenyouneedthishelp.
Ihavedifficultyorneedhelp:
Howoften? • withputtingonorfasteningclothesor
footwear
• withtakingoffclothesorfootwear
• withchoosingtheappropriateclothes
Ihavedifficultyconcentratingor motivatingmyselfandneed:
• encouragingtogetdressedor undressed
• remindingtochangemyclothes
Howoften?
Isthereanythingelseyouwanttotellusaboutthedifficultyyouhaveorthehelpyou needdressingorundressing?
Forexample,youmaygetbreathless,feelpainoritmaytakeyoualongtime.
Yes Tellusinthe boxbelow. No Gotoquestion28.
13
Page 15 of 31 of this pdf
Notes Save Previous page Next page Feedback
Notes Save Previous page Next page Feedback
Help
with
your
care
needs
during
the
day
(continued)
28 Doyou usuallyhave difficultyordoyou needhelp with moving
aroundindoors?
Byindoorswemeananywhereinside,notjusttheplacewhereyoulive.
Pleaseticktheboxesthat applytoyou.
Yes No Gotoquestion29.
Ihavedifficultyorneedhelp:
• walkingaroundindoors
• goingupordownstairs
• gettinginoroutofachair
• transferringtoandfroma wheelchair
Ihavedifficultyconcentratingor motivatingmyselfandneed:
• encouragingorremindingto movearoundindoors
Isthereanythingelseyouwanttotellusaboutthedifficultyyouhaveorthehelp youneedwithmovingaroundindoors?
Forexample,youmayholdontofurnituretogetaboutoritmaytakeyoua longtime.
Yes Tellusintheboxbelow. No Gotoquestion29.
14
Page 16 of 31 of this pdf
Notes Save Previous page Next page Feedback
Notes Save Previous page Next page Feedback
Help
with
your
care
needs
during
the
day
(continued)
29 Doyou fallorstumblebecauseofyour illnessesordisabilities?
Forexample,youmayfallorstumblebecauseyouhaveweakmuscles,stiff jointsoryourkneegivesway,oryoumayhaveproblemswithyoursight,or youmayfaint,feeldizzy,blackoutorhaveafit.
Yes Pleasecontinuebelow. No Gotoquestion30.
Whathappenswhenyoufallorstumble?
Telluswhyyoufallorstumbleandifyouhurtyourself.
Doyouneedhelptogetupafterafall?
Tellusifyouhavedifficultygettingupaftera fallandthehelpyouneedfrom someoneelse.
Yes Pleasecontinuebelow. No
Whendidyoulastfallorstumble?
Ifyoudon’tknowtheexactdate,tellusroughlywhenthiswas.
Howoftendoyoufallorstumble?
Tellusroughlyhowmanytimesyou timeslastmonth.
havefallenorstumbledinthelast monthorinthelastyear.
timeslastyear.
15
Page 17 of 31 of this pdf
03-Mar-09
Save Previous page Next page Feedback
Save Previous page Next page Feedback
Notes
Help
with
your
care
needs
during
the
day
(continued)
30 Doyou usuallyhave difficultyordoyou needhelp with cuttingupfood,eating ordrinking?
Thismeansthingslikegettingfoodordrinkintoyourmouthoridentifyingfoodon yourplate.
Yes Pleasecontinuebelow. No Gotoquestion31.
Pleasetelluswhathelpyouneedandhowoftenyouneedthishelp.
Ihavedifficultyorneedhelp: Howoften?
• eatingordrinking
• withcuttingupfoodonmyplate
Ihavedifficultyconcentratingor motivatingmyselfandneed:
• encouragingorremindingtoeator drink
Howoften?
Isthereanythingelseyouwanttotellusaboutthedifficultyyouhaveorthehelpyou needwithcuttingupfood,eatingordrinking?
Yes Tellusintheboxbelow. No Gotoquestion31.
16
Page 18 of 31 of this pdf
Notes Save Previous page Next page Feedback
03-Mar-09
Help
with
your
care
needs
during
the
day
(continued)
31 Doyou usuallyhave difficultyordoyou needhelp with takingyourmedication or with yourmedical treatment?
Thismeansthingslikeinjections,aninhaler, eyedrops,physiotherapy,oxygentherapy, speechtherapy,monitoringtreatment,copingwithsideeffects,andhelpfrom
mentalhealthservices.Itincludeshandlingmedicineandunderstandingwhich medicinestotake,howmuchtotakeandwhentotakethem.
Yes Pleasecontinuebelow. No Gotoquestion32.
Pleasetelluswhathelpyouneedandhowoftenyouneedthishelp.
Ihavedifficultyorneedhelp: Howoften?
• takingmymedication
• withmytreatmentortherapy
Ihavedifficultyconcentratingor motivatingmyselfandneed:
• encouragingorremindingto takemymedication
• encouragingorremindingabout mytreatmentortherapy
Howoften?
Isthereanythingelseyouwanttotellusaboutthedifficultyyouhaveorthehelp youneedtakingyourmedicationorwithmedicaltreatment?
Yes Tellusintheboxbelow. No Gotoquestion32.
17
Page 19 of 31 of this pdf
03-Mar-09
Save Previous page Next page Feedback
Save Previous page Next page Feedback
Notes
Help
with
your
care
needs
during
the
day
(continued)
32 Doyou usuallyneedhelpfrom anotherpersontocommunicate with other people?
Forexample,youmayhaveamentalhealthproblem,learningdisability,sight, hearingorspeechdifficultyandneedhelptocommunicate.Pleaseanswerasif usingyournormalaids,suchasglassesorahearingaid.
Pleaseticktheboxesthat
Yes applytoyou. No Gotoquestion33.
Ihavedifficultyorneedhelp:
• understandingpeopleIdonot knowwell
• beingunderstoodbypeoplewho donotknowmewell
• inplacesIdonotknowwell
• concentratingorremembering things
• answeringorusingthephone
• readingletters,fillinginforms, replyingtomail
• askingforhelpwhenIneedit
Isthereanythingelseyouwanttotellusaboutthedifficultyyouhaveorthehelp youneedfromanotherpersontocommunicatewithotherpeople?
Forexample,youuseBritishSignLanguage(BSL).
Tellusaboutyour
Yes communicationneeds No Gotoquestion33.
intheboxbelow.
18
Page 20 of 31 of this pdf
Notes Save Previous page Next page Feedback
Notes Save Previous page Next page Feedback
Help with your care needs during the day (co
33 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.
Please continue below. Go to question 34.
Yes No
ntinued)
What you do or would like What help do you need or would How often do
to do. you need from another person to you or would
do this? you do this?
Example I cannot see and my wife has to find Four or five
Listening to music the disc I want and put the disc in times a week
the player.
Tell us about the activities and the help you need from another personat home.
Tell us about the activities and the help you need from another personwhen you go out.
What you do or would like What help do you need or would How often do
to do. you need from another person to you or would
do this? you do this?
Example When I get to the swimming pool I Three times a
Swimming need help to get changed, to dry week for half
myself and to get in and out of an hour each
the pool. time.
If you need some more space to tell us about your hobbies, interests, social or religious activities please continue at question 45Extra information.
19
Notes Save Previous page Next page Feedback
Notes Save Previous page Next page Feedback
Help
with
your
care
needs
during
the
day
(continued)
Please ticktheboxesthat applytoyou.
34 Doyou usuallyneedsomeone to keep aneyeonyou?
Forexample,youmayhaveamentalhealthproblem,learningdisability,sight, hearingorspeechdifficultyandneedsupervision.
Yes Gotoquestion35.
• Imayhearvoicesorexperience thoughtsthatdisruptmythinking.
Isthereanythingelseyouwanttotellusaboutthesupervisionyouneedfrom anotherperson?
Yes Tellusintheboxbelow. No Gotoquestion35.
Page 22 of 31 of this pdf
20
No
Howlongcanyoubesafelyleftforata time?
Pleasetelluswhyyouneedsupervision.
• Topreventdangertomyselforothers.
• Iamnotawareofcommondangers.
• Iamatriskofneglectingmyself.
• Iamatriskofharmingmyself.
• Imaywander.
• Todiscourageantisocialoraggressive behaviour.
• Imayhavefits,dizzyspellsor blackouts.
• Imaygetconfused.
Notes Save Previous page Next page Feedback
03-Mar-09
Save Previous page Next page Feedback
Help
with
your
care
needs
during
the
night
Bynightwemeanwhenthehouseholdhascloseddownattheendoftheday.
35 Doyou usuallyhave difficultyorneedhelp duringthenight?
Thismeansthingslikesettling,gettingintopositiontosleep,beingproppedupor gettingyourbedclothesbackonthebediftheyfall off,getting tothetoilet,using thetoilet,usingacommode,bedpanorbottle,gettingtoandtakingthetabletsor medicinesprescribedforyouandhavinganytreatmentortherapy.
Yes Pleasecontinuebelow. No Gotoquestion36.
Pleasetelluswhat helpyouneed,howoftenandhowlongeachtimeyouneedthis helpfor.
Ihavedifficultyorneedhelp: Howoften? Howlongeachtime?
• turningoverorchanging
positioninbed minutes
minutes • sleepingcomfortably
• withmytoiletneeds minutes
• withmyincontinenceneeds
minutes minutes
• takingmymedication
• withtreatmentortherapy minutes
Ihavedifficultyconcentratingor
motivatingmyselfandneed: Howoften? Howlongeachtime?
• encouragingorremindingaboutmy
toiletorincontinenceneeds minutes
• encouragingorremindingabout
medicationormedicaltreatment minutes
Isthereanythingelseyouwanttotellusaboutthedifficultyyouhaveorthe help youneedduringthenight?
Yes Tellusintheboxbelow. No Gotoquestion36.
21 03-Mar-09
Save Previous page Next page Feedback
Save Previous page Next page Feedback
Notes
Help
with
your
care
needs
during
the
night
(continued)
36 Doyou usuallyneedsomeone to watchover you?
Forexample,youmayhaveamentalhealthproblem,learningdisability,sight,hearing orspeechdifficultyandneedanotherpersontobeawaketowatchoveryou.
Yes Pleaseapplytotickyou.theboxesthat No Gotoquestion37.
Pleasetelluswhyyouneedwatchingover.
• Topreventdangertomyselforothers.
• Iamnotawareofcommondangers.
• Iamatriskofharmingmyself.
• Imaywander.
• Todiscourageantisocialoraggressive behaviour.
• Imaygetconfused.
• Imayhearvoicesorexperience thoughtsthatdisruptmythinking.
Howmanytimesanightdoesanotherperson needtobeawaketowatchoveryou?
Howlongonaveragedoesanotherperson
needtobeawaketowatchoveryouatnight? minutes
Isthereanythingelseyouwanttotellusaboutwhyyouneedsomeonetowatch overyou?
Yes Tellusintheboxbelow. No
22
Gotoquestion37.
03-Mar-09
Save Previous page Next page Feedback
Save Previous page Next page Feedback
Notes
Help
with
your
care
needs
37 Please tell usanythingelse youthinkweshouldknow about thedifficulty youhave orthe helpyouneed.
Ifyouneedsomemorespacetotellusaboutthehelpyouneedorthedifficultyyou havewithyourcareneeds,pleasecontinueatquestion45Extrainformation.
38 When your careneedsstarted
Normally,youcanonlygetAttendanceAllowanceifyouhavehaddifficultyor neededhelpforsixmonths.
Pleasetellusthedateyourcareneedsstarted.
Ifyoucannotremembertheexactdate,tellusroughlywhenthiswas.
23 03-Mar-09
Save Previous page Next page Feedback
Save Previous page Next page Feedback
Notes
About
time
spent
in
hospital,
a
care
home
or
a
similar
place
39 Are youinhospital, acarehome orsimilarplacenow?
Forexample,aresidentialcarehome,nursinghome,hospiceorsimiliarplace.
i
Formoreinformationpleasereadpage9ofthenotes.Yes Telluswhenyouwentin. No Gotoquestion40.
Pleasetellusthefullname andaddressoftheplace whereyouarestaying.
Postcode
Ifyouareinhospital,whydid yougointohospital?
Doesthelocalauthority,NHStrust,primarycaretrustoragovernment department payanyofthecostsforyoutolivethere?
Yes Ifprimary‘Yes’,whichcaretrustauthority,orgovernmentNHStrust, departmentpays?
No
40 Haveyoucomeoutofhospital,acarehomeorsimilarplaceinthepastsixweeks?
Yes Telluswhenyouwentin. No Gotoquestion41.
Telluswhenyoucameout.
Pleasetellusthefullname andaddressoftheplace whereyouwerestaying.
Postcode
Ifyouhavebeeninhospital, whydidyougointohospital?
24
03-Mar-09
Save Previous page Next page Feedback
Save Previous page Next page Feedback
Notes
About
time
spent
in
hospital
(continued)
41 Haveyoubeenin hospitalin thepast twoyears?
Yes Pleasecontinuebelow. No Gotoquestion42.
Whydidyouhavetogointo hospital?
42
Constant Attendance Allowance
Pleaseticktheboxifyouaregettingorwaitingtohearabout:
• WarPensionConstantAttendanceAllowance
• IndustrialInjuriesDisablementBenefitConstantAttendanceAllowance
43
How we pay you
i
Youmustreadpage10ofthenotesabouthowwepayyoubefore youtickoneoftheboxesbelow.25 IfweareabletopayyouAttendanceAllowance,wewillpaythebenefitin
thesamewayasyourStatePensionorPensionCredit.
Tickifyouagreetobepaidthiswayandunderstandtheinformation aboutbeingoverpaidonpage10ofthenotes–Howwepayyou.
Tickifyoudonotagree,ordonotreceiveStatePensionorPension Credit.Wewillcontactyouaboutthis.
03-Mar-09
Save Previous page Next page Feedback
Save Previous page Next page Feedback
Notes
Statement
from
someone
who
knows
you
44
Statement
from
someone
who
knows
you
Please note, this statement does not have to be filled in.
Ifyoudowantthisstatementtobefilledin,thebestpersontodoitistheonewhois mostinvolvedwithyourtreatmentorcare.Thismaybesomeoneyouhavealready toldusaboutonthisform.
Ifyouaresigningthisformonbehalfofthedisabledperson,pleasegetsomeoneelse tofillinthissection.
Howoftendoyouseethepersonthisformisabout?
Pleasetelluswhattheirillnessesanddisabilitiesare,andhowtheyareaffectedby them.
Tellusyourjob,professionorrelationshiptothepersonthisformisabout.
Yourfullname
Youraddress
Postcode
Daytimephonenumber,
wherewecancontactyouor leaveamessage
Yoursignature
Date
26
Page 28 of 31 of this pdf
Notes Save Previous page Next page Feedback
03-Mar-09
Save Previous page Next page Feedback
Notes
Extra
information
45
Extra information
Pleasetellusanythingelseyouthinkweshouldknowaboutyourclaim.
Ifyouneedmorespacecontinueonpage29.PleaseputyournameandNational Insurancenumberonanyextrapiecesofpaperyousendus.
27
03-Mar-09
Save Previous page Next page Feedback
Save Previous page Next page Feedback
Notes
46
Declaration
We cannotpayanybenefituntilyouhavesignedthedeclaration,andreturned theformtous.Pleasereturnthesignedformstraightaway.
IdeclarethattheinformationIhavegivenonthisformiscorrectand completeasfarasIknowandbelieve.
IunderstandthatifIknowinglygivefalseinformation,Imaybeliable toprosecutionorotheraction.
IunderstandthatImustpromptlytelltheofficethatpaysmyAttendance Allowanceofanythingthatmayaffectmyentitlementto,ortheamountof, thatbenefit.
IunderstandthattheDepartmentmayusetheinformationwhichithasnow ormaygetinthefuturetodecidewhetherIamentitledto:
•the benefitIamclaiming,
•anyotherbenefitIhaveclaimed,
•anyotherbenefitImayclaiminthefuture. ThisismyclaimforAttendanceAllowance.
Date Signature
Printyournamehere
Haveyousignedanddatedtheconsentquestion16onthisclaimform?
Forinformationabouthowwecollectanduseinformation,see
i
page10ofthenotes.What
to
do
now
Checkthatyouhavefilledinallthequestionsthatapplytoyouorthepersonyou areclaimingfor. Makesureyouhavesignedtheconsentquestion16andthe declarationquestion46.
Sendtheclaimformtotheofficethatdealswiththeareawhereyoulive (seeWheretosendthecompletedformonthelastpage).
Pleaselistallthedocumentsyouaresendingwiththisclaimformbelow.
Forexample,aprescriptionlist,medicalreport,orcareplan.
i
Forhelpandadviceaboutotherbenefits,seepage11ofthenotes. 28Please remember to sign and date the form after printing.
03-Mar-09
Save Previous page Next page Feedback
Save Previous page Next page Feedback
Notes
Notes
Extra
information
(continued)
Name
NationalInsurance number
29 03-Mar-09
Save Previous page Next page Feedback
Save Previous page Next page Feedback
Notes
We would like your feedback
about this PDF claim form
In this PDF form we have introduced a special feature that
lets you save it in Adobe Acrobat Reader 5.1 and later. This
means that you no longer have to complete the form in one
session.
We would like your feedback about this form so that we can
improve future versions.
Please email your comments to this email address:
For help or 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.
If you are having technical difficulties
:
• downloading the form
• navigating around the form
• moving from page to page, or
• printing a hard copy
Contact the
eService helpdesk
Phone:
0845 601 80 40
Minicom (textphone):
0845 601 80 39
Email:
[email protected]
Opening hours
Monday to Friday: 08:00am - 09:00pm
Weekend: 08:00am - 04:00pm
Closed on all Public and Bank Holidays
Thank you.
1. Disability Benefits Centre
PO Box 30 Chester CH70 8AN
2. Disability Benefits Centre
PO Box 35 Bristol BS80 8AJ
3. Attendance Allowance Team
Palatine House Preston
PR1 1HB
4. Disability Benefits Centre
PO Box 37 Glasgow G90 8AS
5. Disability Benefits Centre
PO Box 33 Leeds LS88 8AF
6. Disability Benefits Centre
PO Box 32 Preston PR11 2BB
7. Disability Benefits Centre
PO Box 34 Birmingham B99 1AR
8. Attendance Allowance Team
Palatine House Preston
PR1 1HB
9. Disability Contact and Processing Unit Government Buildings Warbreck House Warbreck Hill Blackpool FY2 0YJ
10. Disability Benefits Centre
PO Box 36 Cardiff CF91 5AT
11. Disability Benefits Centre
PO Box 31 London SW95 9BD
Where to send the completed form
Please send the completed claim form to the office that deals with the area where you live. These are shown on the attached map. Please note, the office that deals with your area may be in another part of the country.
Blackpool Disability Contact and Processing Unit Disability Contact and Processing Unit
Government Buildings Warbreck House Warbreck Hill Blackpool
Lancashire FY2 OYJ
Phone: 08457 123456 Fax: 01253 331 266
Email: [email protected]
For existing disability claims
You can contact:
If you are still not sure where to send the form
Phone the Benefit Enquiry Line (BEL). The number is 0800 88 22 00. Textphone 0800 24 33 55(for hearing or speech difficulties).
back
back
Zoom in Zoom out
Zoom in Zoom out
