Pension Credit Your application form Applying for Pension Credit The quickest way to apply for Pension Credit is by phone. A friend or family member can call for you. You must be with them when they call. Pension Credit claim line: nidirect.gov.uk • Freephone: 0808 100 6165 • Textphone: 0808 100 2198 Lines are open 9am to 5pm Monday to Friday, except public holidays. If you need help with this form Before you fill in this form, please read the bookletNotes to help you fill in the form that came with this form After you have read the notes and if you still need help to fill in the form you can ask a friend or phone the Northern Ireland Pension Centre on the number above. If this is hard for you to read We can provide this information in a different way such as large print or in other formats. Please get in touch with us for more information on how we can help you. About your application Please make sure you: • Answer all the questions on the form that apply to you and your partner, if you have one, and any child or young person you wish to claim for • Sign and date the form and send it back to us with all the documents we have asked for by at the latest. If we get your form back after this date it may affect the date we can pay you from. If you have received a Housing Benefit HB2 (PC) form, please check it and if correct sign and return it, along with this form to the Northern Ireland Pension Centre. Don’t forget to send us any documents we have asked for. Unfortunately original bank statements will not be returned. This is usually within 5 working days of us getting them but sometimes can take longer. Version 01/20 PC1(NI)NSP Part 1: About You Please fill in this form with BLACK INK and in CAPITALS Title Mr/Mrs/Miss/Ms/Other Your surname or family name All your other names, in full Any other surnames or family names you have been known by or are using now. Include maiden names, all former married names and all changes of surname or family name Date of birth Letters Numbers Letter Your National Insurance number You can get this from your payslips, NI number card, tax papers or letters about social security benefits. Your permanent address Postcode Your contact address If it is different from above Postcode Daytime phone number If you have one What is this number? Home Work Mobile Textphone Please tick If you provide your mobile phone number we may contact you by text message to deal with your claim, or any queries you may have, as quickly as possible. Your textphone number if you have one, for people with speech or hearing difficulties Are you registered blind or No severely sight impaired Yes 2 Part 1: About you continued Are you able to speak to us in No English? Yes If you answered No, please tell us the language you would like us to use when we speak to you. Tick here to show if you want us Braille to contact you about this claim in Text Relay one of these ways. Large Print If you choose one of these options, Audio every time we contact you about Sign Language your application we will do it in that Induction Loop way, if we can. Textphone Number 3 Part 2: About your partner Do you have a partner? No Go to Part 3. We use ‘partner’ to mean: Yes Tell us about this below. • 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. Does your partner live No permanently in a care home? Yes Go to Part 3. Are you separated from No your partner? If you are separated only because Yes Go to Part 3. someone is temporarily in a hospital or care home, tick No. Does your partner agree to you No Please still tell us as much as you can about your partner making this application? Yes Your partner’s title Your partner’s surname or family name Your partner’s other names in full Any other surnames or family names your partner has been known by or is using now Include maiden names, all former married names and all changes of surname or family name. Your partner’s date of birth Letters Numbers Letter Your partner’s National Insurance (NI) number You can get this from their payslips, National Insurance number card, tax papers or letters about social security benefits. Is your partner registered blind No or severely sight impaired? Yes 4 Part 3: About any child/children and Qualifying Young People you want to claim for Please read Part 3 of the booklet Notes to help you fill in the form before you fill in this part. Do you want to claim Pension No Go to Part 4: About where you live. Credit for any children or Yes Please give details of the child/children and qualifying qualifying young people? young people you want to claim for below. If you want to claim for more than 2 children/qualifying young people please provide more details in Part 12 of this form. Where the form refers to a ‘child’, you should also use this to tell us about any qualifying young person you are claiming for. How many children do you want to claim for? Child 1 Child 2 First name Last name Sex of child Child’s date of birth What date do you want to claim for the child/children from? What date did you become responsible for the child? Does the child live with you all of No If No, how often do No If No, how often do the time? they live with you, they live with you, e.g. 3 days a week? e.g. 3 days a week? Where else does the Where else does the child live? child live? Who do you Who do you share caring share caring responsibilities with? responsibilities with? Yes Yes 5 Part 3: About any child/children and Qualifying Young People you want to claim for continued If you have only just taken over responsibility for the child, who was responsible for them before you? Do you receive Child Benefit for No Who claims Child No Who claims Child this child? Benefit for this child? Benefit for this child? Yes What is the Child Yes What is the Child Benefit reference Benefit reference number? number? Numbers Letters Numbers Letters CHB CHB Is the child aged between No No 16 and 19? Yes If yes, is the child in Yes If yes, is the child in full time education, full time education, non-advanced non-advanced education or an education or an approved training approved training course? course? No No Yes If yes, when Yes If yes, when did the non- did the non- advanced advanced education education or approved or approved training training start? start? Is the child looked after by the No No local authority not including Yes Yes respite care? Is the child in prison or custody No No pending trial or sentence? Yes Yes 6 Part 3: About any child/children and Qualifying Young People you want to claim for continued Is the child currently away from No No home, but in Northern Ireland? Yes If yes, how long Yes If yes, how long in total are they in total are they expected to be expected to be absent for? absent for? If more than 52 If more than 52 weeks, why is the weeks, why is the child away from child away from home? home? Is the child currently outside No No Northern Ireland? Yes If yes, how long Yes If yes, how long in total are they in total are they expected to be expected to be absent for? absent for? If more than 4 weeks, If more than 4 weeks, why is the child why is the child absent from absent from Northern Ireland? Northern Ireland? 7 Part 3: About any child/children and Qualifying Young People you want to claim for continued Is the child entitled to Disability No No Living Allowance? Yes If yes, what rate Yes If yes, what rate of Disability Living of Disability Living Allowance is the child Allowance is the child entitled to? entitled to? Care Component Care Component highest rate highest rate Care Component Care Component middle rate middle rate Care Component Care Component lowest rate lowest rate Mobility Mobility Component Component higher rate higher rate Mobility Mobility Component Component lower rate lower rate Is the child entitled to Personal No No Independence Payment? Yes If yes, what Yes If yes, what rate of Personal rate of Personal Independence Independence payment is the child payment is the child entitled to? entitled to? Daily living Daily living enhanced rate enhanced rate Daily living Daily living standard rate standard rate Mobility Mobility enhanced rate enhanced rate Mobility Mobility standard rate standard rate Is the child certified as severely No No sight impaired or blind by a Yes Yes consultant ophthalmologist? Have you claimed Tax Credits in the No No last 12 months? Yes Yes Are you still claiming Tax credits? No If no when did the Tax No If no when did the Tax Credit claim come to Credit claim come to an end? an end? Yes Yes 8 Part 4: About where you live Do you live permanently in a No care home? Yes Do you own the property No Go to Part 5.