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04-Jan-06 Claim form for people who need to buy things for a baby Page 1 of 15 of this pdf Sure Start Maternity Grant from the Social Fund Part of the Department for Work and Pensions Can you get a Sure Start Maternity Grant You may be able to get a Sure Start Maternity Grant if G you or your partner are getting Income Support or income-based Jobseeker s Allowance or Pension Credit or Working Tax Credit which includes a disability or severe disability element or Child Tax Credit at a rate higher than the family element. From April 2005 to April 2006 this means a Child Tax Credit rate of 548 a year or more or 1096 a year or more if you have a baby under one. 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. G When to claim and you need help with buying things for a baby that has recently been born or is expected to be born in the next 11 weeks or you have recently adopted or is the subject of a parental order under section 30 of the Human Fertilisation and Embryology Act 1990. SF100 12/05 But you must be the mother or expectant mother of the baby and you must be aged 16 or over or be the partner of the mother or expectant mother or have adopted the baby or be getting benefit for the mother or expectant mother if she is aged under 19 or have been granted a parental order with your husband or your wife under section 30 of the Human Fertilisation and Embryology Act 1990. You must claim in the period from 11 weeks before the week your baby is due until 3 months after your baby is born* If you are waiting for a decision on a qualifying benefit or entitlement you must still claim within the time limit* If you are adopting a baby baby. The baby must not be more than one year old when you claim* If you have been granted a parental order under section 30 of the Human Fertilisation and Embryology Act 1990 the order. Notes About your claim Help and advice How we collect and use information If you want more information The Department for Work and Pensions collects information for the purposes of dealing with social security child support vaccine-damage issues employment and training private pensions policy and retirement planning. The information we collect about you depends on the reason for your business with us but we may use the information for any of these purposes. We may check information about you with other information we have. We may get information about you from other people and certain other organisations. We may give information to certain other organisations as the law allows to Get in touch with your local office. You can find the phone number and address on the advert in the business numbers section of the phone book. Look under Jobcentre Plus or Social Security. See also leaflet GL18 Help from the Social Fund available from any of our offices and SB16 A guide to the Social Fund* which can be found on our website. The address is www.dwp*gov*uk Advice Bureau. The Sure Start Programme In some parts of the country there are local Sure Start Programmes offering help to the parents of children aged under four. These bring together a range of services including health learning through play and family support. The Sure Start Maternity Grant is different because it is paid direct to parents who qualify no matter where they live in Great Britain* These notes give general guidance only and should not be treated as a complete and authoritative statement of the law. check the accuracy of information prevent or detect crime protect public funds in other ways and use in research or statistics. These other organisations include other government departments local authorities and private-sector bodies such as banks and organisations that may lend you money. We will not give information about you to anyone outside our department unless the law allows us to. Controller for the purposes of the Data Protection Act. If you want to know more about what information we have about you or the way we use your information please contact us. You can contact any of our offices and ask for leaflet GL33 Data Protection Act 1998 It affects you. Or you can find a copy of the leaflet on our website. The address is www.dwp*gov*uk Keep this page for your information About you and your partner Part 1 Please use this form to claim a Sure Start Maternity Grant from the Social Fund* Fill in this form in ink and sign and date any alterations you make. Make sure that you read the notes before you fill in this form* Tell us about yourself and your partner if you have one. We use partner to mean Fill in the form fully by answering all the questions and requests for information* Your application may be delayed if we do not have all the information we need* Remember you must claim in the period from 11 weeks before the week your baby is due until 3 months after your baby is born If you have adopted the baby you must claim within 3 months of the adoption* You Surname or family name Your partner Sure Start Maternity Grant from the Social Fund Mr / Mrs / Miss / Ms All other names in full / Date of birth Your address Please tell us your address. Tell us your partner s address if different. Postcode Letters Numbers National Insurance NI number You can find the number on your National Insurance NI numbercard letters about your benefit or payslips If you do not know your NI number have you ever had one or used one at any time No Yes Any other surnames or family names you have been known by or are using now. Include maiden name all former married or civil partnership names and all changes of family name. Daytime phone number What is this number Please tick Part 2 Code Home work mobile fax About benefits and entitlements Are you or your partner getting Income Support claim for Income Support Jobseeker s Allowance an application for Pension Credit disability or severe disability element claim for Working Tax Credit which includes a Credit at a rate higher than the family element 548 a year or more or 1096 a year or more if you have a baby under one. a claim for Child Tax Credit at a rate higher than the family element Are you receiving benefit for the mother of the baby or an expectant mother because she is under 19 years of age Please tell us her name trade dispute We use trade dispute to mean a strike a walkout a lockout or another dispute at How long have you or your partner not been working because of a trade dispute If this is less than 6 weeks we cannot make a payment. Part 3 If a baby is expected So that we can consider your application for a Sure Start Maternity Grant the certificate SSMG cert which is on the back page of this application form must be filled in by a health professional* For example your midwife. For office use SSMG cert received Other approved docs Is more than one baby expected How many babies are expected Initials ................................. Please make sure that the document you are sending with this claim form tells us the number of babies that are expected* Date ......... / .......... / ........... Part 4 About babyand your partner born If the you has already been In case of a still birth you do not have to send the certificate SSMG cert but so that we can consider your application you must provide us with evidence of the birth. Have you or your partner adopted the baby or babies What was the date of adoption Please send the adoption papers with this claim form* Have you and your husband or your wife been granted a parental order under section 30 of What date were you granted the order Part 5 General information Has a Sure Start Maternity Grant from the Social Fund already been paid to either you or someone else for this baby or babies Who was it paid to We can only make another Sure Start Maternity Grant if you G are adopting the baby or G you and your husband or your wife have been granted a parental order under section 30 of the Human Fertilisation and Child Benefit If you want to claim Child Benefit claim forms are available direct from HM Revenue and Customs. Phone 0845 603 200 or visit www.hmrc*gov*uk Part 6 Making payments to you We normally pay Social Fund directly into an account. This is the safest way to pay you and lets you choose how and when you get your money. You can use a bank or building society. You may be able to use a cash machine which will usually mean you can get your money at any time of the day or night. Most of these machines can be used for free but some of them will charge you to take your money out. If so you will be warned by a message on the screen* This will give you the opportunity to cancel your transaction without being charged* There are arrangements with banks and building societies so that you can collect cash from some of their accounts at your Post Office branch. The Post Office also provides a bank account that we can pay benefits and entitlements into. With this account you can only collect your money in cash from Post Office branches during opening hours. A Payment direct into an account How you will be paid Your Social Fund will be paid into the account stated in Part B. Finding out how much is paid into the account We will tell you when the payment will be made and how much it is for. You can check account statement shows your payment details but not your National Insurance NI number. If you think your payment is wrong get in touch with the office that pays you. Getting someone to collect your Social Fund payment with this please contact your bank building society or the Post Office if you have a Post Office card account. If not enough money is paid into the account If we do not pay enough money into the account we will make another payment or add the money we owe you onto your next payment. We will contact you to tell you what we are going to do. Sometimes we pay too much money into the account and you may be overpaid If this is because of the way the system works for payments direct into an account we have the right to recover any money you are not entitled to. For example you may give us we may not be able to change the amount already sent out. We will contact you first if we propose to recover any money. Please go to Part B if you want to tell us about the account you want to use for your Social Fund payment. or Part C if you are unable to tell us about the account now or want information about how your payments can be made by other means. B About the account you want to use Tick this box if you agree to be paid directly into an account and understand the information in Part A about being overpaid* Please give your account details on the next page. You must fill in ALL the boxes including the building society roll or reference number if you have one. the details ask the bank or building society or the Post Office if it is a Post Office card account. Whose name or names is the account in Please tick one box. Please note G A Post Office card account can only be in your name. with as if you are married to them or G By ticking the box for an account that includes the name of the person acting on your behalf you confirm that you will authorise them to use the money in the way you tell them or you are an appointee acting on behalf of the customer. In your name In the name of your partner In the name of the person acting on your behalf What name or names is the account in Please write the name or names as they appear on the cheque book passbook or statement. Full name of bank or building society For a Post Office card account write Post Office. Sort Code of the bank building society or Post Office card account Please tell us all six numbers for example 12-34-56. Account number. This is seven to ten numbers long. More information if it is a building society account number. The number is on the passbook. You may be getting other benefits and entitlements that are not paid direct into an account at the moment. If you now agree to have them paid into this account please tell us the names of the benefits or entitlements. The roll or reference can contain letters and numbers and can be up to 18 characters long. If you are not sure if the account has a roll or reference number ask the building society. C If you did not complete section B Please read the notes below then tick Box 1 or Box 2. If you have an account but you do not wish to use it for example a joint account any bank or building society will help you open an account that suits you better. Remember to ask whether their accounts allow you to get your money from the Post Office if this is important to you. Basic bank account If you have had problems opening a current account or if you are worried about being overdrawn you could ask any bank or sometimes called introductory or starter accounts and are available from all major banks. These accounts offer free banking but overdrafts are not available. You can use these accounts to pay money in pay bills automatically and get cash out. Many basic bank accounts also allow you to get cash from What to do now Tick the box that applies to you. Box 1 I intend to open an account. Complete the claim form and send it to us now. Do not wait until you have opened an account. Any bank or building society will help you open an account. If you want to get your money at the Post Office check that the account allows you to do this. If you want us to pay into an account tell us your account details as soon as you have them* I would like information about how I can be paid by other means. Box 2 This is a simple bank account that can only have benefit pension entitlement allowance or tax credit payments paid into it. You can only collect payment from it in cash at a Post Office branch during opening hours. You will not have a cheque book and cannot withdraw money at a cash machine. You will not be able to run up an overdraft pay bills by Direct Debit or Standing Order or have your salary or any other money paid in* The account can only be in your name. You may be able to arrange with the Post Office for someone else to collect your benefit regularly from this account. Part 7 Other information Post Office details Please provide details of your local Post Office You can use this space to tell us anything else you think we might need to know. If there is not enough space please use a separate sheet of paper. Make sure that you put your full name and National Insurance NI number on it. Part 8 For people filling in and signing this form for someone else Have you filled this form in for someone else Go to Part 9. signing this form for someone else. I am sending a letter signed by the customer with this form* The letter tells you that they agree to me making the claim for them* Now sign this form in Part 9. I am their appointee I have power of attorney Full name Address Phone number Please tick Declaration Part 9 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 information that is incorrect or incomplete I may be liable to prosecution or other action* I agree to my award being paid directly into the account I have chosen if I have given account details on this form* I understand if I have given account details on this form that the Department has the right to recover overpayments caused by the way the system works for direct payment as described on page 7 of this form* anything that may affect my entitlement to or the amount of any award. Signature Date Look through this form and check that you have answered all the questions and given all the information requested* need* Check that you have signed this form* Check that the health professionals statement has been completed by your midwife or other health professional* send the originals as we cannot accept photocopies. But do not delay sending in this form* Send or take this form to your local office. You can find the phone number and address on the advert in the business numbers section of the phone book. Look under Jobcentre Plus or Social Security. If you do not have an envelope you can get one from your local Post Office . It will not need a stamp* This is my claim for a Sure Start Maternity Grant. You must send this claim form to us from 11 weeks before the week But remember you must claim before the baby is 3 months old. of adoption* But this must be before the baby is one year old. If you have a parental order under section 30 of the Human Fertilisation and Embryology Act 1990 you must claim within 3 months of the date of What happens next We will look at your claim as soon as we can* If we can pay you a Sure Start Maternity Grant we will send a payment to the account you have chosen* If we cannot pay you a Sure Start Maternity Grant we will write to you to tell you why. Health professional s statement SSMG cert To be completed by the health professional only I certify that ............................................................................... insert name of parent consulted me in respect of ...................... insert words and number e.g one 1 expected child or children Tick and complete as appropriate. expected in the week that includes born on has received advice as appropriate on aspects of Tick the appropriate box es and delete any which do not apply. maternal health the health of the unborn child the health and welfare of the new child. Date of consultation Date of signing Authentication stamp or for midwives/health visitors who do not have an authentication stamp details of surgery/office address contact telephone number and UKCC PIN*