BR1 Pension Form – Fill Out and Use This PDF

About your State Pension

Your State Pension is based on the National Insurance (NI) contributions you have paid, or have been treated as paying, or been credited with, during your working life. There may be different parts in your State Pension, for example basic State Pension and additional State Pension.

We can tell you how much State Pension you will get. Call us on 0800 731 7898.

If you are not entitled to the full rate of basic State Pension you may be able to increase the amount you get by paying voluntary NI contributions for past years.

New rules for paying additional voluntary contributions from 6 April 2009

Customers may be able to improve their basic State Pension by paying up to an additional six years of voluntary National Insurance contributions for tax years from 6 April 1975 if:

-they reach State Pension age between 6 April 2008 and 5 April 2015

-already have 20 qualifying years (including full years of Home Responsibilities Protection).

Customers who reached State Pension age between 6 April 2008 and 5 April 2010 must have at least one paid, or treated as paid, qualifying year.

Payment for the additional years must be made within six years of the date you reach State Pension age. They can be paid in addition to any voluntary National Insurance contributions you may be able to pay under the usual time limits.

Additional voluntary National Insurance contributions cannot be paid for any tax year the whole of which is covered by a married woman’s or widow’s reduced rate election.

If you do not already have the 20 qualifying years needed to pay additional voluntary National Insurance contributions you may be able to get them by paying some voluntary National Insurance contributions under the usual time limits.

If you want to know if you can increase your basic State Pension in this way, get in touch with us. You can ask us about this at any time, even if you do not want to claim your State Pension yet.

To find out more about the rates of basic State Pension

●call us on 0800 731 7898

●visit www.gov.uk/state-pension

●ask for a leaflet about social security benefit rates from Jobcentre Plus.

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Improving your State Pension

If you are married or a civil partner

Sometimes you won’t get State Pension based on your own National Insurance contributions, or your basic State Pension will be less than the full rate. But you may be able to get basic State Pension based on your husband’s, wife’s or civil partner’s National Insurance contributions if you are

●a woman married to a man, and your husband has reached State Pension age, or

●a married man, and your wife

–was born on or after 6 April 1950 and

–has reached State Pension age, or

●a woman married to a woman, a man married to a man or a civil partner, and your husband, wife or civil partner

–was born on or after 6 April 1950 and

–has reached State Pension age.

The earliest a man married to a man or a male civil partner will be able to get a basic State Pension based on his husband’s or civil partner's National Insurance record is

6 April 2015, as this is the date a man born on 6 April 1950 reaches State Pension age.

If you are a married woman and your spouse legally changes gender from male to female during your marriage, you may be able to have your basic State Pension improved by using her contributions even if she was born before 6 April 1950. This is the same treatment as if she had not legally changed her gender.

If you are divorced

You may be able to get an increase of basic State Pension by using your ex-husband or wife's National Insurance contributions.

If your civil partnership has been dissolved

You may be able to improve your basic State Pension by using your ex-civil partner's National Insurance contributions.

If you have been widowed

You may be able to improve your basic State Pension by using your late husband or wife's National Insurance contributions. But you will not be able to improve your basic State Pension by using the National Insurance contributions of your late husband or wife if

●you were under State Pension age when your husband or wife died, and

●you remarry or form a civil partnership before you reach State Pension age.

If you were widowed on or after 9 April 2001 and get a bereavement benefit like Bereavement Allowance or Widowed Parent's Allowance, you will stop getting that benefit when you reach State Pension age. You will then normally be entitled to State Pension instead.

If you were widowed before 9 April 2001 and get a widow's benefit like Widow's Pension or Widowed Mother's Allowance, you can

●claim State Pension from State Pension age, or

●keep getting your Widow's Pension until you are 65, or

●keep getting your Widowed Mother's Allowance for as long as you are entitled to it, or

●give up your widow's benefit to earn extra State Pension.

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Improving your State Pension continued

If you are more than thirty days away from reaching your State Pension age, you can get a State Pension statement to help you decide what to do. It will tell you if you will get more money by claiming State Pension instead of your widow's benefit.

If you are a surviving civil partner

You may be able to improve your basic State Pension by using your late civil partner's National Insurance contributions. But you will not be able to improve your basic State Pension by using the National Insurance contributions of your late civil partner if

●you were under State Pension age when your civil partner died, and

●you form a new civil partnership or marry before you reach State Pension age.

If you are entitled to Widowed Parent’s Allowance or Bereavement Allowance because of the death of your civil partner, you will stop getting those benefits when you reach State Pension age. You will then normally be entitled to State Pension instead.

Getting an estimate of your State Pension

A State Pension statement will tell you how much you may get when you claim your State Pension. Your State Pension Statement will be based on your own National Insurance Contributions.

If you would like a statement call the Future Pension Centre straight away. You will not be able to get a statement once you are within thirty days of you State Pension age.

Call them on 0845 3000 168. Lines are open from 8am to 6pm Monday to Friday. They are closed on public holidays. You will be charged at a local rate if you call from a BT landline. Charges for calls from mobile phones and cable networks may be different.

If English is not your first language we can provide an interpreter for you. If you have speech or hearing difficulties, you can contact them using a textphone on 0845 300 0169. Or you can use Text Relay by dialling 18001 0845 3000 168.

All the information you give them is confidential. They may record some calls to monitor their standard of service and for training purposes.

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Tracing a lost occupational or personal pension

If you have changed jobs a number of times during your working life, it is easy to lose contact with an old employer and their pension scheme. The Pension Tracing Service may be able to help you if you are not sure of all the details but you

●think you may have an old occupational or personal pension, or

●think you may be a beneficiary of an old pension scheme, or

●you are acting on behalf of someone else.

Tracing all your pension benefits now will help you make decisions in the future about saving for your retirement. And it will help make sure that you get all the pension benefits that you are entitled to when you retire.

You can trace a pension by:

●calling us on 0845 600 2537. We will do the trace over the phone or send you an application form. Opening hours are Monday to Friday 8am to 6pm.

●visiting www.gov.uk/state-pension

●writing to:

The Pension Tracing Service The Pension Service 9

Mail Handling Site A Wolverhampton WV98 1LU.

We need to know at least the name of your previous employer or pension scheme.

If you have speech or hearing difficulties you can contact us using a textphone on 0845 3000 169.

Or you can use Text Relay by dialling 18001 0845 600 2537.

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Working past State Pension age

If you work past State Pension age, you can increase your income when you retire. This is because you will have more time to earn and save for your future.

If you decide to

●work fewer hours

●job share

●do a less demanding role, or

●do seasonal work

check how it will affect any occupational pension schemes you are paying into.

If you work past State Pension age, you can claim State Pension while you keep working. The money you earn and the hours you work will not affect your State Pension, but you may pay tax on your State Pension as well as the money you earn.

You can also put off your claim to State Pension to earn extra State Pension or a lump sum.

You may be able to keep working with the same employer while they are paying you an occupational pension.

Paying National Insurance contributions past State Pension age

You do not pay Class 1 National Insurance contributions after State Pension age. If you work for an employer and you are past State Pension age, you need to give your employer a Certificate of Age Exception. This certificate tells them that you do not have to pay National Insurance contributions on the money that you earn.

If you tell us that you are going to keep working when you claim your State Pension, this certificate will be sent to you automatically.

If you put off claiming State Pension and need a certificate, contact HM Revenue & Customs. You may have to give them evidence of your date of birth. You can write to them at:

HM Revenue & Customs NICO

Contributor Caseworkers

Benton Park View

Longbenton

Newcastle upon Tyne

NE99 1ZZ.

If you want to find out more about National Insurance, you should contact HM Revenue & Customs. You can find the number in the phone book under HM Revenue & Customs. Or you can visit their website at

www.hmrc.gov.uk

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Putting off your State Pension

You can put off claiming your State Pension when you reach State Pension age. This means we will not pay you State Pension until you claim it. Depending how long you put off your claim, you will be able to get extra State Pension or a lump sum when you do claim. Putting off claiming is also known as 'State Pension deferral'.

For more information about putting off your claim for State Pension see 'When to claim your State Pension' in Part 3 on page 9 of this booklet.

If you are already getting State Pension, you can stop being paid your

State Pension to earn extra State Pension or a lump sum later on. You can only do this once and you must normally live in Great Britain. You can put off claiming State Pension for as long as you like.

Extra State Pension

You can choose to get extra State Pension if you put off claiming your

State Pension for 5 weeks or more. When you do claim, you will get a higher weekly State Pension for the rest of your life.

The amount of extra State Pension you get is 0.2% of your weekly

State Pension for each week you have put off your claim. This works out at 1% for every 5 weeks, and 10.4% for a full year.

When your State Pension increases every April, your extra State Pension will usually increase as well. The State Pension is not increased in all overseas countries.

Lump sum payment

If you put off claiming your State Pension continuously, for at least one year or more in a row, you have two choices. You can get extra State Pension or you can get a lump sum payment instead. You will have to pay tax on the lump sum. We will only pay you the lump sum once.

The lump sum payment is made up of the State Pension you would have got if you had not put off claiming, plus interest. We will add interest to the lump sum payment for each week that you put off claiming. We will add the interest at 2% above the Bank of England’s base rate.

You can get the lump sum when you start to claim your State Pension or in the following tax year. You will also get your normal State Pension when you start claiming.

How putting off your claim is affected by other benefits

If you put off claiming State Pension while getting other benefits, you will not build up any extra State Pension or lump sum for the days that you get the other benefit. These other benefits include:

●Carer’s Allowance

●Severe Disablement Allowance

●Unemployability Supplement

●Widow’s Pension

●Widowed Mother’s Allowance

●Incapacity Benefit

●Pension Credit.

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Putting off your State Pension continued

Also you will not be able to build up extra State Pension or a lump sum for the days that you or your partner, if you have one, get one or more of the following income-related benefits:

●Pension Credit

●Income Support

●income-based Jobseeker’s Allowance

●income-related Employment and Support Allowance.

We use partner to mean

●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.

Taxation

You may have to pay tax on your State Pension. And if you decide to take the extra State Pension, you will have to pay tax on that as well. If you decide to take the lump sum instead of extra State Pension you may have to pay tax on the lump sum.

Extra State Pension will be taken into account for Pension Credit and Housing Benefit, just like other types of income.

The lump sum will not affect your claim for Pension Credit or Housing Benefit.

To find out more about tax and the State Pension visit www.gov.uk

What do I have to do?

You do not have to tell us if

●you want to put off claiming your State Pension, or

●you want to keep putting off claiming it.

But if you get another social security benefit you need to tell us what you want to do.

If you are thinking about putting off your claim, it is important that you find out more about this option before you decide. This booklet can only give general information. There is more information on our website at

www.gov.uk/state-pension

You may also want to get independent financial advice. You may have to pay for this.

If you are currently putting off claiming your State Pension

You may also benefit from the choices available. To find out more, please contact us on 0800 731 7898.

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Notes to help you fill in your claim form

Part 1 – About you

Use this part of the form to tell us your personal details.

Part 2 – About your husband, wife or civil partner

Answer all the questions on the form that apply to your husband, wife or civil partner, if you have one.

If you have told us that you are married or in a civil partnership you should send us your

●marriage certificate, or

●civil partnership certificate.

If you have told us that you are divorced or your marriage has been annulled or your civil partnership has been dissolved you should send us your

●divorce certificate (decree absolute, decree of divorce, certificate of annulment), or

●civil partnership dissolution certificate.

We need to see the original certificate, not a photocopy.

You must remember to send us the certificates we ask for. We will return them within 5 working days. If we need to keep them longer, we will tell you why. Phone us on 0800 731 7898 if any of this will cause you difficulties. If you do not, benefit you can get from this claim may be delayed.

Part 3 – When to claim your State Pension

State Pension payday is a fixed day of the week. Any money that you earn will not affect your State Pension but may affect your income tax.

You will need to contact us to make a separate claim for any State Pension you qualify for based on your husband's, wife's or civil partner's National Insurance record if:

●you qualify for some State Pension based on your own National Insurance record and you claim this before they reach State Pension age, and

●when they reach State Pension age they decide to put off claiming their own State Pension.

Time limits

We can accept your claim if it is received no earlier than 4 months before the date you wish to get State Pension, or the date you reach State Pension age, whichever is the later.

Your State Pension cannot be backdated more than 12 months before the date your claim is received.

If you ask us to backdate your State Pension claim, we will work out how much State Pension you are due, back to the date you tell us you want your claim to start from, and pay you this amount. This payment does not include any interest, and you will not earn extra State Pension or a lump-sum payment for the period you backdate your claim for.

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Notes to help you fill in your claim form continued

Part 3 – When to claim your State Pension continued

Delaying your claim to State Pension

You might want to think about a more flexible approach to your retirement. If you want to, you can continue to work longer, or work part-time, whether or not you have claimed your State Pension.

If you put off claiming your State Pension until a time that suits you, you can get extra State Pension or a one-off taxable lump sum payment.

Depending on how long you put off your claim for, when you finally claim your State Pension, you can choose either:

●extra State Pension, paid for life on top of your normal weekly State Pension, or

●a one-off, taxable lump-sum payment, plus your normal weekly State Pension.

The minimum period you must put off claiming your State Pension to get extra State Pension is 5 weeks, or 12 consecutive months to get a lump sum payment.

Extra State Pension

If you choose extra State Pension, you can get an extra 1% on top of your weekly State Pension for every five weeks that you put off claiming – this is the same as 10.4% extra for every year you put off claiming. So, if you put off claiming for a year, you could get about £1 extra for every £10 of your weekly State Pension.

One-off lump sum payment

This is a one-off payment based on the amount of State Pension you would have received in the period you put off claiming. It also includes interest, which will always be at least 2% above the Bank of England base rate. As well as getting your lump sum, you will also get your weekly State Pension, paid at the normal rate from when you start claiming it.

You can put off claiming your State Pension for as long as you like to build up either extra State Pension or a lump sum. You could also choose to have your State Pension backdated.

Circumstances when putting off claiming your State Pension does not earn extra money

If you put off claiming your State Pension for more than five weeks, there are certain circumstances in which you might not earn extra State Pension. Or if you have put off claiming your State Pension for more than 12 months there are certain circumstances in which you might not earn a lump sum payment. For example if since reaching State Pension age you or your partner have received certain other benefits, or someone else has received an increase of another benefit for you, or you have been in prison.

If you want more information about delaying your claim to State Pension please contact us on 0800 731 7898.

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Notes to help you fill in your claim form continued

Part 4 – How we pay you

Please read these notes before you complete Part 4 of the claim form.

We normally pay your money into an account

Many banks and building societies will let you collect your money at a post office.

We will tell you when the first and second payment will be made and how much each is 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

If we pay you too much money we have the right to take back any money we pay that you are not entitled to. 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.

We will contact you before we take back any money.

About the account you want to use

●You can use an account in your name, or a joint account

●You can use someone else’s account if

–the terms and conditions of their account allow this, and

–they agree to let you use their account, and

–you are sure they will use your money in the way you tell them

●You can use a credit union account. You must tell us the Credit Union's account details. Your Credit Union will be able to help you with this.

●if you are an appointee or legal representative acting on behalf of the customer, the account should be in your name only.

It is very important you fill in ALL the boxes in the claim form correctly, including the building society roll 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.

You can find the account details on your chequebook or bank statements. If you do not know the account details, ask the bank or building society.

What to do now

●Tell us about the account you want to use in Part 4 of the claim form. By giving us your account details you

–agree that we will pay you into an account, and

–understand what we have told you above in the section If we pay you too much money.

●If you are going to open an account, please tell us your account details as soon as you get them.

●If you do not have an account, please contact us and we will give you more information.

Fill in the rest of the claim form. You do not have to wait until you have opened an account or contacted us.

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Notes to help you fill in your claim form CONTINUED

Part 5 – About any time you lived or worked abroad

We need to know about any time you have lived or worked outside the United Kingdom (UK). This is because if you have paid into the social security system in another country, it may count towards your State Pension.

The United Kingdom is England, Scotland, Wales and Northern Ireland.

Please tell us about any time that you lived or worked in

●a country outside the UK, or

●the Channel Islands, or

●Ireland.

Do not tell us about any time that you were overseas with HM Forces.

Part 6 – About your National Insurance (NI) contributions

Use this part of the form to tell us if you have been working prior to reaching State Pension age and give us details of your employment.

Part 7 – About time in hospital

We need to know if you are in hospital at any time when you are getting State Pension. For more information on how periods in hospital affect your benefit, contact The Pension Service and ask for a leaflet about going into hospital.

Part 8 – About other benefits or entitlements

We need to know if you or your husband, wife or civil partner are receiving or waiting to hear about any of the following benefits:

●Attendance Allowance

●Bereavement benefits

●Carer’s Allowance

●Child Benefit

●Disability Living Allowance

●Employment and Support Allowance

●Graduated Retirement Benefit

●Guardian’s Allowance

●Incapacity Benefit

●Income Support

●Industrial Death Benefit

●Jobseeker’s Allowance

●Pension Credit

●Personal Independence Payment

●Reduced Earnings Allowance

●Severe Disablement Allowance

●State Pension

●Temporary Allowance For Widows

●Unemployability Supplement paid because of

–a war disability due to service with HM Forces, or

–an industrial accident or disease

●Universal Credit

●War Widow’s or Widower’s Pension

●Widow's Benefit

●Working Tax Credit.

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Notes to help you fill in your claim form CONTINUED

Part 9 – Other information

Use this part of the claim form to tell us any other information about your circumstances.

Part 10 – Pension Credit

Pension Credit is a tax free payment for those who have reached the qualifying age, and live in Great Britain. By Great Britain we mean England, Scotland and Wales.

The Pension Credit qualifying age is gradually going up to 66 in line with the increase in the State Pension age for women to 65 by November 2018 and the further increase to 66 for men and women between December 2018 and December 2020.

To find out when you can get Pension Credit visit

www.gov.uk/pension-credit-calculator

Or ask for a leaflet about Pension Credit from your pension centre, and look at the tables at the back.

If you have a partner, and only one of you has reached the qualifying age you can still get Pension Credit. The person who has reached the qualifying age must be the one who applies.

There are two parts to Pension Credit:- the Guarantee Credit and the Savings Credit.

The Guarantee Credit works by topping up your weekly income to a guaranteed minimum level.

If you or your partner are aged 65 or over and you have saved some money towards your retirement, like a second pension or savings, you may get the Savings Credit.

If you are getting or applying for Pension Credit while you are putting off claiming your State Pension, we will work out your Pension Credit as if you were getting your State Pension.

We cannot pay Pension Credit instead of the State Pension you have chosen to put off.

To apply for Pension Credit you can call us on 0800 99 1234. If you have speech or hearing difficulties you can contact us using a textphone on 0800 169 0133.

If you want to know more about Pension Credit, ask when you contact us about your State Pension. Or visit www.gov.uk/pension-credit

When you call us we will ask you about your circumstances. For example we may ask you about any income, savings and investments you and your partner have.

If you apply for Pension Credit, we can also help you apply for Housing Benefit at the same time.

Part 11 – Declaration

It is important that you sign and date the claim form. If you do not, we will have to send it back to you.

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When you have filled in your claim form

1.Check that you have answered all the questions on your claim form that apply to you.

2.Check that you are sending us any documents we may have asked for.

These could be your:

●marriage certificate

●civil partnership certificate

●certificate of annulment

●certificate of civil partnership dissolution

●decree absolute

●decree of divorce.

3.Check that you have signed the form in PART 11.

4.Send your claim form and any documents to us.

If there is no reply envelope, please phone The Pension Service on 0800 731 7898.

People with speech or hearing problems using a textphone can dial 0800 731 7339.

5.When to claim

If you want to claim your State Pension now, send your claim form to us.

Benefit you can get because of this claim can be paid more quickly if you

●answer all the questions on this form that apply to you and your husband, wife or civil partner, if you have one

●send us any documents we may have asked for.

If you cannot do this, get in touch with us. But any benefit you can get as a result of this claim may be delayed, or lost altogether.

6.You can get an electronic version of this booklet and a claim form from our website. For more information, go to www.gov.uk/cymraeg

7.You may be entitled to Pension Credit. For more information call the freephone number 0800 99 1234.

What happens next

We will write to tell you how much State Pension you can get and when it will be paid from.

If you are not entitled to State Pension we will tell you why.

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More information

How the Department for Work and Pensions collects and uses information

When we collect information about you we may use it for any of our purposes. These include dealing with

●social security benefits and allowances

●child support

●employment and training

●financial planning for retirement

●occupational and personal pension schemes.

We may get information about you from others for any of our purposes if the law allows us to do so. We may also share information with certain other organisations if the law allows us to.

To find out more about how we use information, visit our website www.dwp.gov.uk/privacy-policy or contact any of our offices.

More information

For more about State Pension you can visit our website at www.gov.uk, or by phoning 0845 731 3233.

For more information about tax and the State Pension you can visit HMRC's website www.hmrc.gov.uk/pensioners

You cannot claim an increase of your State Pension for children or qualifying young persons. However, you can claim Child Tax Credit instead. To find out more about Child Tax Credit or claim online visit www.hmrc.gov.uk/taxcredits

You can also phone HM Revenue & Customs by calling the helpline on 0845 300 3900. If you have speech or hearing difficulties, you can contact the helpline using a textphone on 0845 300 3909.

Lines are open 8am to 8pm 7 days a week, except Christmas Day, Boxing Day, New Year’s Day and Easter Sunday.

If you need help or a form in Welsh, please telephone 0845 302 1489. Lines are open 8.30am to 5pm, Monday to Friday.

The Pension Service can give you advice about Attendance Allowance, Carer’s Allowance, Winter Fuel Payments, Housing Benefit and Funeral Payment.

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Useful contacts

Other contacts you may find useful

Disability Benefits

If you have access to the internet you can find claim forms, guidance and information at www.gov.uk

By answering some simple questions you can check if you are entitled to a range of benefits by visiting www.gov.uk/benefitadviser

Carer’s Allowance Unit

Phone 0845 608 4321

(Textphone 0845 604 5312)

For advice and information for people who look after someone who is disabled.

NHS-funded nursing care in care homes

Phone 0300 123 1002 (England) or 029 2082 5295 (Wales)

For a free copy of the leaflet ‘NHS Funding Care in Nursing Homes – what it means for you’.

Help The Aged and Senior Line

Phone: 0808 800 6565 (free)

(Textphone: 0800 269 626)

E-mail: seniorline@helptheaged.org.uk

An advice line providing information for older people with problems such as benefits and pensions.

Winter Fuel Payment Centre (EEA residents only)

Phone +44 (0)191 218 7777

Winter fuel payment advice for people living outside the UK but within the European Economic Area or in Switzerland.

Royal National Institute for Deaf People (RNID)

Phone 0808 808 0123

(Textphone 0808 808 9000)

Website: www.RNID.org.uk

For information and resources for deaf and hard of hearing people, their families and friends.

Age Concern Information Line

Phone: 0800 009 966

Website: www.ageconcern.org.uk

For information and advice on issues that affect older people within the UK.

Citizens Advice

Website: www.citizensadvice.org.uk

For basic advice, including advice on pensions. You can find the number of your local bureau in the phone book.

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Part 1: About you

Please fill in this form with

BLACK INK and in CAPITALS

Letters Numbers

Letter

Please tell us your National

Insurance (NI) number

You can find your NI number on your NI number card, letters from social security or payslips.

If you do not know your NI number,	No
have you ever had one or used one	Yes
at any time?

2

Part 1: About you continued

Are you able to speak to us	No
in English?	Yes
If you answered No, please tell us
the language you would like us to
use when we speak to you.
If you live in Wales, do you	No
want to speak to us in Welsh?	Yes

Part 2: About your husband, wife or civil partner

What is your current marital	Single	Please go to Part 3.
or civil partnership status?	Married or civil partner
	Divorced or civil partnership dissolved
	Marriage or civil partnership annulled
	Separated
	Widowed or surviving civil partner
Tell us about your husband, wife or
civil partner
Their surname or family name

Their other names

Letters Numbers

Letter

Their National Insurance (NI) number

Their address, if different from yours

Postcode

Their date of birth	/	/

3

Part 2: About your husband, wife or civil partner continued

Please send us your marriage or civil partnership certificate, certificate of annulment, certificate of civil partnership dissolution or decree absolute. In Scotland this is called a DECREE OF DIVORCE.

Part 3: When to claim your State Pension

Please read Part 3 of your Notes booklet to help you fill in this part.

For official use only

4

Part 4: How we pay you

Please read Part 4 of your Notes booklet to help you fill in this part.

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 chequebook or 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.

You may get other benefits and entitlements we do not pay into an account. If you want us to pay them into the account above, please tick the box.

We normally pay your benefit every 4 weeks.

If you are only getting a small State Pension, the arrangements may be different. Please contact us for more information using our phone number shown on the front of this form.

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Part 5: About any time you lived or worked outside the United Kingdom or the Isle of Man

What is your nationality?

If you have lived or worked in more than 2 countries, tell us about them in PART 9.

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Part 6: About your National Insurance (NI) contributions

If you are a married woman or
a widow
• have you been self-employed	No
at any time since 6 April 1978?	Yes
• have you been paying reduced	No
rate NI contributions?	Yes

If you have had more than 2 employers, tell us about them in PART 9.

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Part 7: About time in hospital

Name of hospital

Address and postcode of hospital

Postcode

Ward name or number

Part 8: About other benefits or entitlements

Please read Part 8 of your Notes booklet to help you fill in this part.

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Part 8: About other benefits or entitlements continued

Benefit or entitlement 1

Name of the benefit or entitlement

Who is getting or waiting to hear	You
about this?	Your husband, wife
	or civil partner
Reference number.
This is on letters about the benefit
or entitlement
Benefit or entitlement 2
Name of the benefit or entitlement
Who is getting or waiting to hear
	You
about this?	Your husband, wife
	or civil partner
Reference number.
This is on letters about the benefit
or entitlement
	If you or your husband, wife or civil partner get more than
	2 benefits or entitlements, tell us about them in PART 9.

Have you received Child Benefit	No
at any time since 1978?	Yes

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Part 9: Other information

Use this space to tell us anything else you think we might need to know. You can continue on a separate piece of paper if you need to.

If you continue on a separate piece of paper, make sure you

•write your full name, address and NI number on it

•sign and date it.

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Part 11: Declaration

I understand that I must promptly tell The Pension Service, by phone or in writing, of anything that may affect my entitlement to, or the amount of my State Pension.

I declare that the information I have given on this form is correct and complete as far as I know and believe.

I understand that if I knowingly give false information, my benefit may be stopped and I may be liable to prosecution or other action.

I understand that if I fail to promptly notify the Department of a change in circumstances, I may be liable to prosecution or other action.

This is my claim to State Pension.

Signature

Date

/ /

We will only acknowledge your claim if you are sending a

•marriage certificate

•civil partnership certificate

•certificate of annulment

•certificate of civil partnership dissolution

•decree absolute or

•decree of divorce.

For office use only

If you are applying for State Pension, you only need to fill in the boxes below if we ask you to.

I have read back to the customer the entries I made on this form based on the information they gave me. The customer agreed they were correct.

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B. Please tell us which ethnic background you feel you belong to.

Prefer not to say

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