Help using this PDF claim form
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If you are having technical difficulties:
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Please contact the DWP Online helpdesk.
Phone: 0800 169 0154
Email: dwponline.helpdesk@dwp.gsi.gov.uk
Opening hours
Monday to Friday: 8am - 6pm
Closed on weekends and all Public and Bank Holidays.
For help and advice on the information you need to put on the form or
about the beneft you want to claim, contact the offce that deals with the
beneft.
Calls to 0800 numbers are free from landlines or mobiles.
State Pension
statement
Please tear off and keep for your information.
What is a State Pension statement?
A State Pension statement will give you an estimate of how much
State Pension you may get and the earliest date you can claim.
The estimate will be based on your National Insurance contribution
record as it stands on the date the statement is produced.
Your State Pension statement is not a guarantee. The amount you
get when you claim your State Pension may be different from the
amount on your statement. You may want to get financial advice
before making decisions based on your State Pension statement.
Who can get a State Pension statement?
You can get a State Pension statement if you are aged 16 or over
and at least 30 days away from your State Pension age when we
look at your application.
Completing the form
Please fill in the form in black ink and send to the address below.
You must sign the form in Part 7 – if you do not your application
may be delayed.
If you need any help, please call us on 0800 731 0175 (if you live in
the UK) or +44 191 218 3600 (if you live outside the UK). You can
also write to us at:
Newcastle Pension Centre, Futures Group
The Pension Service 9
Mail Handling Site A
WOLVERHAMPTON
GREAT BRITAIN
WV98 1LU
Other ways to get a State Pension statement
If you live in the UK you can get a State Pension statement by calling
us on 0800 731 0175. Lines are open Monday to Friday 8am to
6pm. For security and quality purposes your call may be monitored
and recorded.
If you have speech or hearing difficulties you can contact us using a
textphone on 0800 731 0176.
If you live outside the UK
You can call us by dialling +44 191 2183600 to get a State Pension
statement. Lines are open Monday to Friday 8am to 6pm. If you
have speech or hearing difficulties you can contact us using a
textphone on +44 191 2182051. BR19 07/18
Call to 0800 numbers are free from landlines and mobile.
How long will it take to get my statement?
We will normally send you a State Pension statement within 10 working days of
receiving your application.
Sending your State Pension statement to someone else
If you would like us to send your State Pension statement to someone else,
please tick the box in Part 5 and fill in Part 6.
We can only send your State Pension statement to someone else if:
l they have an existing Power of Attorney, or
l you give us your permission in writing to do this now
If you are making the application on behalf of someone you are authorised to
act for, we will need to see proof of that authority before we can send you their
State Pension statement.
Claiming State Pension
You cannot use this form to claim your State Pension. This form is to get a
State Pension statement.
To find out how to claim your State Pension go to
www.gov.uk/state-pension/how-to-claim
How the Department for Work and Pensions collects and
uses information
When we collect information about you we may use it for any of our purposes.
These include dealing with:
l social security benefits and allowances
l child support
l employment and training
l financial planning for retirement
l occupational and personal pension schemes
We may get information about you from others for any of our purposes if
the law allows us to do so. We may also share information with certain other
organisations if the law allows us to.
To find out more about how we use information, visit our website www.gov.uk
State Pension
statement
Application for a State Pension statement
Part 1 About you
Please tell us about yourself. Use BLOCK CAPITALS and black ink.
Letters Numbers Letter
National Insurance (NI) number
Title Please choose
Current surname or family name
First name and any middle names
Any other surnames or family
names you have previously been
known by
Date of birth – DD/MM/YYYY
Full address including postcode
or zip code
Correspondence address
if different from above. Give us
the full address, including the
postcode or zip code.
Have you ever worked or No
paid National Insurance in
the Isle of Man? Yes
BR19 07/18
Application for a State Pension statement continued
Part 2 Marital status
Please tick the description that applies to you and give exact dates as DD/MM/YYYY.
Single
Married Date of marriage
If you converted or changed your civil partnership into
a marriage, or married your civil partner, enter the date
your marriage is treated as starting on.
Civil partner Date of formation of
civil partnership
Divorced Date of marriage
If you converted or changed your civil partnership into
a marriage, or married your civil partner, enter the date
your marriage is treated as starting on.
Date of divorce
Civil partnership dissolved Date of formation of
civil partnership
Date of dissolution
Widowed Date you were married
If you converted or changed your civil partnership into
a marriage, or married your civil partner, enter the date
your marriage was treated as starting on.
Date you were widowed
Surviving civil partner Date of formation of
civil partnership
Date your civil partner
died
Part 3 Contact details
If we need to contact you before By letter to the address given in Part 1.
we send you your State Pension
statement, how would you prefer By phone.
us to get in touch with you? Please give number below.
Home phone number
Daytime phone number, if different
What is this number? Work Mobile Textphone
If you live in Wales, we can English
send you your State Pension
statement in English or Welsh. Welsh
Which language do you prefer?
We can send you your Braille
State Pension statement in
braille or large print. Large print
Please tick a box if you prefer
one of these choices.
2
Application for a State Pension statement continued
Part 4 Living outside the United Kingdom
We use United Kingdom (UK) to mean England, Scotland, Wales and Northern Ireland.
If you are currently living in the UK please go to Part 5.
If you are currently living outside the UK, please tell us:
Your last two UK addresses,
including postcodes
Address 1
Address 2
The date you left the UK
Use DD/MM/YYYY.
3
Application for a State Pension statement continued
Part 5 What to do now
Please tick the box that applies to you. If you tick both boxes,
we will only send the State Pension statement to you.
Where do you want your State Pension statement sent?
To me at the address I have Please go to Part 7.
given in Part 1.
To my representative. Please go to Part 6.
I want my representative to
handle any follow-up enquiries
that relate to my State Pension
statement.
Please note that:
l this authorisation relates only to enquiries made to the
Newcastle Pension Centre, Futures Group and
l we can only provide information to your representative for
the period that your State Pension statement is held on our
computer records
If you request another State Pension statement in the future,
you would need to provide further authorisation for us to
provide or discuss that statement with your representative.
I am a Personal Acting Body. Please go to Part 6.
Send the State Pension Please provide proof of your authority.
statement to me. For example, power of attorney.
A Personal Acting Body is a
named person appointed to look
after all or some aspects of a
customer’s affairs.
4
Application for a State Pension statement continued
Part 6 Your representative
Please give details of your representative.
If you are a Personal Acting Body, please give your name and address.
Title
Surname or family name
Other names
Organisation’s name
if this applies.
Full address including postcode
or zip code
Daytime phone number
Fax number
Reference number
if you know it
Please go to Part 7.
Part 7 Signature
Please sign and date this form.
Signature
Please sign the form here after printing
Date DD/MM/YYYY
Where to send this form
Send this form to
Newcastle Pension Centre, Futures Group
The Pension Service 9
Mail Handling Site A
Wolverhampton
WV98 1LU
United Kingdom
