Health, Well-being and Care

Marital Status

Please select single: aged under 25 single: aged 25 to 59 single: aged 60 to 64 single: aged 65 and over single parent: aged under 18 single parent: aged 18 and over couple: eldest aged under 18 couple: eldest aged 18 to 59 couple: eldest aged 60 to 64 couple: eldest aged 65 and over
By 'Couple' we mean anyone who you are married to, or in a civil partnership with, or live with as if you are married or civil partners.

Are you or your partner registered blind?

No Yes

Do you live permanently in a Care Home?

No Yes

Do you or your partner get Attendance Allowance or the care component of Disability Living Allowance?

No Yes (One of us) Yes (Both of us)

How many children aged under 16 do you have?

How many children aged 16 to 18 do you have?

How many of your children are aged under 1 year old?

Do you have any children who are registered blind or receive Disability Living Allowance?, if yes how many?

Are you or your partner entitled to Carer's Allowance?

Does anyone get Carer's Allowance for looking after you?

Family Premium
Are you a lone parent who was receiving Housing Benefit on 05/04/98?

Are you (or your partner) receiving one of the following:

Attendance Allowance;
Constant Attendance Allowance;
Disability Living Allowance;
The disabled element of Working Tax Credit;
Disabled Person's Tax Credit;
Incapacity Benefit (Higher Rate);
Invalid Carriage;
Invalidity Pension;
Mobility Allowance;
Registered disabled;
Registered blind;
Severe Disability Allowance;
Unable to work for 51 weeks due to ill health

Are you (or your partner) receiving any of the following:

Attendance Allowance;
Constant Attendance Allowance;
Severe Disablement Allowance;
Exceptionally Severe Disablement Allowance;
Registered disabled;
Receiving care component of Disability Living Allowance (higher and middle rates);

And have no one aged 18 and over (other than your partner) living with you

And you (or your partner) are not receiving Invalid Care Allowance / Carers Allowance

Does the above apply to both you and your partner ?

Your Income

Are you or your partner receiving Income Support, Jobseeker's Allowance (Income Based), or the Guarantee Credit component of Pension Credit?

What are your, and your partners (if applicable), total working hours per week?

If you have no dependant children, please select the option for whichever one of you works the longest hours.

How much is your net weekly wage?

How much is your partners net weekly wage?

(net wage = Your Wage minus Tax, National Insurance and 50% of any private pension payment)

Unearned Income (please enter the gross weekly amount you get)

Please note: If your Local Authority does not operate a local scheme to disregard War Widow's Pension or War Disablement Pension in full, then these incomes should be entered as 'Any Other Income' minus your Local Authority’s relevant disregard.

You

Partner

Attendance Allowance

Child Benefit

Childcare vouchers

Disability Living Allowance

Child Tax Credit

Employment Credit

Fostering Allowance

Guardian's Allowance

Incapacity Benefit

Industrial Disablement or Injuries Pension

Industrial Death Benefit

Jobseekers' Allowance (Contribution Based)

Local Exchange Trading Scheme

Maintenance Received

Maternity Allowance

Money from lodgers

Money from sub-tenants

New Deal grant

Private Pension / Works Pension

Retirement Pension

Severe Disablement Allowance

War Disablement Pension (disregarded)

War Widows Pension (disregarded)