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Part 2 - About children

We need to know about any children in your household. This includes 16 to 20-year-olds who
are still in education.

Are there any children living with you?
If No, go to Part 3

Child 1 Child 2 Child 3
Last name or surname

First name
Date of birth

Male or Female

Relationship to you
Registered blind? Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ]

Disability Living Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ]
Allowance/Personal
Independence Payment
(PIP)?

Child Benefit Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ]

Child 4 Child 5 Child 6

Last name or surname

First name
Date of birth

Male or Female
Relationship to you

Registered blind? Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ]

Disability Living Yes [ ] No [ ] Yes [ ] No [ ]
Allowance/Personal Yes [ ] No [ ]
Independence Payment
(PIP)?
Child Benefit Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ]

* Do you pay child minding fees to a registered childminder or nursery? Yes No
Y
s
e

N
o
If Yes, we will write to you about this.
‘Must be registered with Local Authority/Ofsted.
If there are more than six children, please continue on a separate sheet.

HB/CTB 07 04/2013 5 SF-B-0035
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