[ Pobierz całość w formacie PDF ]

The letter tells you that they
agree to me making the claim
for them.
I am their appointee
I have power of attorney
Full name Mr / Mrs / Miss / Ms
Date of birth / /
Address
Postcode
Code Number
Phone number
Home work mobile fax
What is this number?
Please tick
Now sign this form in Part 9.
11
Page 14 of 15 of this pdf
27-Mar-07
Declaration
Part 9
This is my claim for a Sure Start Maternity Grant.
I declare that the information I have given on this form is correct
and complete as far as I know and believe.
Signature
I understand that if I knowingly give information that is incorrect or
incomplete, I may be liable to prosecution or other action.
I understand that I must promptly tell the office that pays my
benefit of anything that may affect my entitlement to, or the amount
of, any award.
Date
/ /
What to do now
Part 10
Look through this form and check that you have answered all the You must send this claim form to us from 11 weeks before the
questions and given all the information requested. Your application week your baby is due.
may be delayed if we do not have all the information we need.
But remember, you must claim before the baby is 3 months old.
Check that you have signed this form. If you are adopting the baby or have been granted a residence
order, you must claim within 3 months of the date of adoption or
Check that the health professionals statement has been completed
residence order. But the baby must not be more than one year old
by your midwife, or other health professional.
when you claim.
Check that you are sending all the documents we have asked for.
If you have a parental order under section 30 of the Human
Please send the originals as we cannot accept photocopies. But do
Fertilisation and Embryology Act 1990, you must claim within
not delay sending in this form.
3 months of the date of that order.
Send or take this form to Jobcentre Plus. You can find the phone
number and address in the business section of the phone book.
Look under Jobcentre Plus.
What happens next
Part 11
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.
12
Page 15 of 15 of this pdf 27-Mar-07
About professional s statement
Healthyou and your partner 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 / / (health professionals only)
born on / / ,
has received advice, as appropriate, on aspects of
Tick the appropriate box or boxes and delete any which do not apply.
maternal health and the health and welfare of the child  pre-confinement consultation
the health and welfare of the new child  post-confinement consultation
Date of consultation
/ /
Date of signing
/ /
Health professional s signature
Authentication stamp or, for midwives/health visitors
Health professional s name (please print or use a stamp)
who do not have an authentication stamp, details of
surgery/office address, contact telephone number and
UKCC PIN. [ Pobierz całość w formacie PDF ]