Citizens Advice Bureau

Benefits Checklist

Please complete the following form, and we will reply to you as soon as possible. This is rather a long form, but it will enable us to determine whether you are claiming all the benefits that you can.

Personal details
Name:
Address - Street:
District:
Town/City:
Post Code:
Telephone Number:
Email Address:
Preferred Method of Reply:

About You
Personal situation:
How many children:
Council Tax bill:
Housing Status:
Date of Birth:
Disability or Sickness Benefit:
War or War Widows Pension:
State Retirement Pension:
JSA:
Income Support:
Widowed Parents/Mothers Allowance:
Widows Pension or Bereavement:
Maternity Allowance/SMP:
Paternity - Adoption Pay:
Carers Allowance:
Rent:
Rent Free Weeks:
Ground Rent:
Service Charges:
Do you share with non-dependents:
Any Other Income:
Savings:
Disability Premium if known:
or Severe Disability Premium:
Carers Premium:
Anyone inc children receiving JSA:
Industrial Injuries Disability Benefit:
Mortgage Payments:
Outstanding Mortgage:
Date When Mortgage taken out:
CTC WTC already in receipt:

	You	Partner
Hours worked:
Gross earnings:
Pension Contributions:
Childminders RV:
Gross income previous year:
Are you blind:
Long term health problems:
Disabilities:
Message: such as any other matter not listed above
I accept that my data will be retained by the CAB in accordance with the terms of the Data Protection Act

Please answer all relevant questions, then hit the Send button above.

Lichfield and District Citizens Advice Bureau
29 Levetts Fields, Lichfield, Staffordshire WS13 6HY, England
01543 252730 01543 414255

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