Benefits Entitlement Questionnaire

Section 1 - Your Contact Details




Email
Letter
No Preference

Please complete the details of EVERY person in your house including children in the form below.

When you are finished adding a person, press 'Submit'.

You will then be given the option to submit details of additional people.

Person 1.



Please tick the box if this person receives any of these benefits.

DLA Low
DLA Higher / PIP standard
DLA Higher / PIP enhanced
DLA Low / PIP standard
DLA Higher / PIP enhanced
Motability Car
Attendance Allowance Low
Attendance Allowance High

Please state how much of the following benefits this person receives:

Weekly
Monthly
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