Application For Benefit While Temporarily Away From Home
This form is to apply for benefit while you are living away from your home. If you give false information, or you do not tell us information that is relevant, you may be prosecuted under the Theft Acts 1968 and 1978 or the Social Security Act 1992.
Your Details
 Your Name
 Your Date of Birth
 National Insurance (NI) Number
 Contact Address
 Contact Telephone
Claim Details
 The address you are claiming for (including Postcode)
 What date did you move into this address?
 What date did you leave or intend to leave this address?
 Does anyone still live at the property?

 Do you intend to return to this property?

 Please give the full reasons why you are away or will be away
Prison
If you are in prison, please answer the following questions:
 What date were you taken into custody?
 What date were you sentenced or are you going to be sentenced?
 If you have been sentenced, how long is the sentence you have received?
Residential Care
If you are in residential care, please answer the following questions:
 What date did you go into residential care?
 Is this a trial stay?

Information
 Please fill in the space below to give us any extra information.
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