UC no work requirements £ – UC work preparation group £ – UC all work related requirements £ – Pension Credit £ Carers Allowance £ £ Do you receive child benefit? Yes No £ Week / Month (If yes, please state child(s) full name and date(s) of birth) Job Seekers Allowance Yes/No Date Amount Income Support £ ESA support group £ – ESA work related activities £ – Are you waiting to hear any benefits? UC– work focused interview £ UC no work requirements £ – What are they? UC work preparation group £ – What date did you claim? UC all work related requirements £ – Pension Credit £ Carers Allowance £ £ Sort Code: Bank / Post Office account details: Account Number: Name of Bank: How much is currently in your account? £ Do you have any other savings / income? Yes No £ Week / (stocks, shares, ISAs, property) Do you have any pensions? Yes No Doctor’s name and address: Nationality: (if not British please state the date that you arrived in the UK) In order to process this application you must submit copies of the following documents with this referral form:- of benefit entitlement (benefits award letter or two months’ bank statements) Proof of National Insurance number (benefits award letter) Proof of ID (passport, benefits award letter or current utility bill)
UC – no work requirements £ UC – work preparation group £ UC – all work related requirements £ Pension Credit £ Carers Allowance £ £ Do you receive child benefit? (If yes, please state child(s) full name and date(s) of birth) Yes No £ Week / Month Are you waiting to hear any benefits? What are they? What date did you claim? Job Seekers Allowance Yes/No Date Amount Income Support £ ESA – support group £ ESA – work related activities £ UC– work focused interview £ UC – no work requirements £ UC – work preparation group £ UC – all work related requirements £ Pension Credit £ Carers Allowance £ £ Bank / Post Office account details: Sort Code: Account Number: Name of Bank: How much is currently in your account? £ Do you have any other savings / income? (stocks, shares, ISAs, property) Yes No £ Week / Do you have any pensions? Yes No Doctor’s name and address: Nationality: (if not British please state the date that you arrived in the UK) In order to process this application you must submit copies of the following documents with this referral form:- of benefit entitlement (benefits award letter or two months’ bank statements) Proof of National Insurance number (benefits award letter) Proof of ID (passport, benefits award letter or current utility bill)
My-Space-Referral-Form.docx