Backdating your benefit claim Benefits - claimant details Are you completing this form on behalf of someone else? yes no Name of person competing the form on the claimant’s behalf Relationship to the claimant Provide the reason why the claimant cannot complete the form Title Required Miss Mr Mrs Ms Other / not stated First name Required Last name Required Date of birth Required Email address Required Main telephone number National Insurance number Required Benefit claim reference number, if known Your benefit claim reference number is 8 numbers long and can be found on your benefit award notice. Providing your benefit claim reference number will help to process your form quicker. Address Required Postcode Lookup Enter your address Complete this section, even if someone else has filled in this form for you. You must agree to this declaration. Read this declaration carefully before agreeing. I declare that the information I give on this form is correct and complete Required yes I understand that if I give information that is incorrect and incomplete, the council may take action against me yes
