2

my vouchers?
What can I buy with
• plain fresh, dried

• plain fresh, frozen

• infant formula

• plain cow's milk

or tinned pulses

vegetables
or tinned fruit and
child locally.

can exchange your vouchers

or health visitor where you
Make sure you ask your midwife
And don’t forget your vitamins.
on 0345 607 6823.
or call the Healthy Start helpline
to www.healthystart.nhs.uk
nearest participating shops go
as supermarkets. To find your
and greengrocers as well
You can use them at local shops
for vitamins for you and your
/vitamins/
for-health-professionals
www.healthystart.nhs.uk/
exchange vitamin vouchers
You can also find where to

Tear along dotted line

Application form for Healthy Start vouchers
Fill in this application form clearly in black ink, in English and in CAPITAL letters V5

1 You: Please fill in the details of the person who is applying (this is you, if you are pregnant)

Title Surname Date of birth D D M M Y Y Y Y

First Name National Insurance number

Email

Tick all the benefits you are getting:

Income Support Income-related Employment and Support Allowance Income-based Jobseeker’s Allowance Pension Credit
Child Tax Credit (with a family income of £16,190 or less per year) Universal credit (with a family take home pay of £408 or less per month

2 Your address and telephone number: Please tell us where you live and your current telephone number

Line 1

Line 1

Town Country

Postcode Telephone number

3 Your partner – if they live with you: This could be your husband, wife, boyfriend or girlfriend

Title Surname Date of birth D D M M Y Y Y Y

First Name National Insurance number

Relationship to applicant

Tick all the benefits you are getting:

Income Support Income-related Employment and Support Allowance Income-based Jobseeker’s Allowance Pension Credit
Child Tax Credit (with a family income of £16,190 or less per year) Universal credit (with a family take home pay of £408 or less per month

4 Your carer and carer’s partner: Only fill this in if you are under 18 (or under 20 and in full-time education)
and live with a carer – e.g. a parent

4 a Your carer
Title Surname Date of birth D D M M Y Y Y Y

First Name National Insurance number

Relationship to applicant

Please turn over HS01_V5

 1
a voucher for free vitamins. Vitamin
a child under four, you’ll also get
And if you’re pregnant, or have

of one, you get two vouchers baby or child. Helping them to

• For each baby under the age tablets for you; drops for your
grow up strong and healthy.
So what vouchers

• For each child aged over one

and under four, your family
gets one voucher a week
get one voucher a week

a week worth a total of

• If you’re pregnant you
do I get?

worth £3.10

worth £3.10
£6.20

4 b Your carer’s partner (if over 18 years old and living with you)
Title Surname Date of birth D D M M Y Y Y Y

First Name National Insurance number

Relationship to applicant

Tick all the benefits you are getting:

Income Support Income-related Employment and Support Allowance Income-based Jobseeker’s Allowance
Pension Credit Child Tax Credit (with a family income of £16,190 or less per year)
Universal credit (with a family take home pay of £408 or less per month

4 c Complete if you are 18 or 19 years old, in full-time education and pregnant

I am included in my carer’s/carer’s partner’s claim for:
Income Support Income-related Employment and Support Allowance Income-based Jobseeker’s Allowance
Pension Credit Child Tax Credit (with a family income of £16,190 or less per year)
Universal credit (with a family take home pay of £408 or less per month

5 Your children: Please give details of any children (under 4) you already have (continue on another
of paper if necessary)

First Name Date of birth D D M M Y Y Y Y

Surname

First Name Date of birth D D M M Y Y Y Y

Surname

First Name Date of birth D D M M Y Y Y Y

Surname

6 Are you pregnant? Yes No Estimated date of delivery D D M M Y Y Y Y

7 Please read this

Please read this If you are 16 or over, sign and date the form I declare that the information given on this form and in any
yourself. If you are under 16, ask a parent or carer to sign and supporting documents provided is complete and accurate.
date the form. I understand and accept that if I provide false or misleading
information I may be withdrawn from the scheme and I may be
By signing: liable to prosecution and / or civil proceedings.
I understand that the information I have provided will be used
to assess my application for Healthy Start and to issue Healthy
Start vouchers.
Signature
We will use this information to check your application and to
support the effective and efficient delivery of the Healthy Start Name
scheme. The information on this form may be disclosed in
confidence to other public bodies as appropriate for the
purposes of checking entitlement and preventing or Date D D M M Y Y Y Y
detecting fraud.

From the 6 April 2020, we do not need a health professional signature