Claim form for people who need to buy things for a baby

Sure Start Maternity Grant

from the Social Fund

Can you get a Sure Start Maternity Grant?

You may be able to get a Sure Start Maternity Grant if But you must
● apart from other babies from the same pregnancy and ● be the mother or expectant mother of the baby
– your new baby is the only child under 16 in your ● you need help with buying things for a and you must be aged 16 or over, or
family, or baby that ● be the partner of the mother or expectant
– your dependant’s new baby is her only child under – has recently been born, or mother, or
16 in your family. – is expected to be born in the next
Please note that there is an exception to the child 11 weeks, or ● be getting benefit for the mother or expectant
under 16 rule in the case of multiple births. – was recently born and you have become mother aged under 20 of a baby, or

● you or your partner are getting the responsible parent but are not the ● be the responsible parent (but not the mother)
– Income Support, or mother’s partner, or of a baby, and not be the mother’s partner, or
– income-based Jobseeker’s Allowance, or – is the subject of an adoption or residence ● have been granted an adoption or residence
– income-related Employment and Support order, or order for a baby, or
Allowance, or – is the subject of a parental order in
respect of a surrogate birth, or ● have been granted a parental order with your
– Universal Credit, or partner under section 30 of the Human
– Pension Credit, or – has been placed with you for adoption, or
– you have been appointed the guardian of, Fertilisation and Embryology Act 1990 or
– Working Tax Credit which includes a disability or section 54 of the Human Fertilisation and
severe disability element, or or
– you have adopted overseas. Embryology Act 2008, or
– Child Tax Credit at a rate higher than the
family element. ● have had a baby placed with you for adoption
From April 2014 to April 2015 this means a rate of by an agency, or
£548 a year or more. These figures are for a whole ● have been appointed the guardian of a baby, or
year and will be less for part-years. Your tax
We use partner to mean ● have adopted a baby overseas and this falls
credits award notice will include a breakdown of
within section 66(1)(c)–(e) of the Adoption and
your award. If your Child Tax Credit total is greater ● a person you are married to or a person you
live with as if you are married to them, or Children Act 2002.
than the amounts shown as the family elements
you may qualify for a Sure Start Maternity Grant. ● a civil partner or a person you live with as if
you are civil partners.

SF100 04/14
Notes About your claim

When to claim Help and advice How the Department for

● If you are waiting for a decision on a qualifying If you want more information Work and Pensions collects
● get in touch with Jobcentre Plus.
benefit or entitlement, or you have asked for your
Phone 0345 608 8545. You can also call
and uses information
Child Tax Credit award to be reviewed, you must still
claim within the time limits. 0845 608 8545. Check with your phone When we collect information about you we
company which code is cheaper for you. may use it for any of our purposes. These
● If you are expecting a baby or have recently had a You can also get more information from include dealing with:
baby, you must claim in the period from 11 weeks www.gov.uk ● social security benefits and allowances
before the week the baby is due until 3 months after ● child support
the baby is born. or
● employment and training
● If you are not the mother but have become the ● get in touch with an advice centre like the ● financial planning for retirement
responsible parent of a baby, you must claim within Citizens Advice Bureau. ● occupational and personal pension
3 months of becoming responsible. The baby must schemes.
not be more than one year old when you claim. Our service standards We may get information about you from
● If you have been granted an adoption order or At Jobcentre Plus we aim to provide a high others for any of our purposes if the law
residence order for a baby standard of customer service at all times. allows us to do so. We may also share
You must claim within 3 months of the date on the Details of the standard of service you can expect information with certain other
order. The baby must not be more than one year old from us can be found on our website at organisations if the law allows us to.
when you claim. www.dwp.gov.uk/about-dwp To find out more about how we use
● If you have been granted a parental order with your You can access our website from many libraries. information, visit our website at
partner for a baby www.dwp.gov.uk/privacy-policy or contact
For more information please contact any of our offices.
You must claim within 3 months of the date on the
Jobcentre Plus.
order. The baby must not be more than one year old
when you claim.
● If you have been appointed guardian of a baby
You must claim within 3 months of the date the
guardianship takes effect. The baby must not be more
than one year old when you claim.
● If you have had a baby placed with you for adoption
You must claim within 3 months of the date the baby is
placed with you. The baby must not be more than one These notes give general guidance only
year old when you claim. and should not be treated as a complete
● If you have adopted a baby overseas and authoritative statement of the law.
You must claim within 3 months of the adoption taking
effect or being recognised. The baby must not be more
than one year old when you claim.
Tear off this page to keep for your information

▲
Part 1 About you and your partner
● Please use this form to claim a Sure Start Maternity Grant from ● Remember, if you are waiting for a decision on a qualifying benefit or
the Social Fund. Sign and date any alterations you make. entitlement, or have asked for your Child Tax Credit award to be reviewed,
you must still claim within the time limits. These are:
● Fill in this form with BLACK INK and in CAPITALS.
– if you, your partner, or dependent child, are expecting a baby or have just had
Make sure that you read the notes before you fill in this form. a baby, claim in the period 11 weeks before the week your baby is due until
● Tell us about yourself and your partner, if you have one. We use 3 months after your baby is born
partner to mean – if you are not the mother but have become the responsible parent of a baby,
– a person you are married to or a person you live with as if you claim within 3 months of becoming responsible
are married to them, or – if you have an adoption order, a residence order or a parental order for the
– a civil partner or a person you live with as if you are baby, claim within 3 months of its date
civil partners. – if you have been appointed guardian of a baby, claim within 3 months of the
● Fill in the form fully by answering all the questions and requests guardianship taking effect
for information. Your claim may be delayed if we do not have all – if a baby has been placed with you for adoption, claim within 3 months of this
the information we need. – if you have adopted a baby overseas, claim within 3 months of the adoption
taking effect or being recognised.

You Your partner

Sure Start
Surname or family name Mr / Mrs / Miss / Ms Mr / Mrs / Miss / Ms
Maternity
Grant
All other names in full
from the
Date of birth / / / /
Social Fund
Your address
Please tell us your address.
Tell us your partner’s
address, if different.

Postcode Postcode

Letters Numbers Letter Letters Numbers Letter

National Insurance (NI)
number
You can find the number on a National Insurance (NI) numbercard, letters about benefit, or payslips.

If you do not know your NI No No

number, have you ever had Yes Yes
one or used one at any time?

SF100 04/14 1
Part 1 About you and your partner continued

You Your partner

Any other surnames or family names you have

been known by or are using now.
Include maiden name, all former married or civil
partnership names and all changes of family name.
Code Number Code Number
Daytime phone number, if you have one
Mobile phone number Code Number Code Number

Part 2 About benefits and entitlements

You Your partner
Are you or your partner getting No No
Universal Credit? Yes Yes

Are you or your partner waiting to hear about No No

a claim for Universal Credit? Yes Yes
Are you or your partner getting No No
Income Support? Yes Yes

Are you or your partner waiting to hear about No No

a claim for Income Support? Yes Yes

Are you or your partner getting income-based No No

Jobseeker’s Allowance? Yes Yes

Are you or your partner waiting to hear about a No No

claim for income-based Jobseeker’s Allowance? Yes Yes

Are you or your partner getting income-related No No

Employment and Support Allowance? Yes Yes

Are you or your partner waiting to hear No No

about an application for income-related Yes Yes
Employment and Support Allowance?
2
Part 2 About benefits and entitlements continued
You Your partner

Are you or your partner getting Pension Credit? No No

Yes Yes

Are you or your partner waiting to hear about an No No

application for Pension Credit? Yes Yes

Are you or your partner getting No No

Working Tax Credit which includes a Yes Yes
disability or severe disability element?

Are you or your partner waiting to hear about No No

a claim for Working Tax Credit? Yes Yes

Are you or your partner getting Child Tax Credit No No

at a rate higher than the family element? Yes Yes
From April 2014 to April 2015 this means a rate
of £548 a year or more.

Are you or your partner waiting to hear about a No No

claim for Child Tax Credit at a rate higher than Yes Yes
the family element?

Are you or your partner waiting to hear about a No No

review of your Child Tax Credit award? Yes Yes

Are you receiving benefit for the parent of the No

baby, or an expectant mother, because they Yes Please tell us their name
are under 20 years of age?

Are you or your partner involved in a No

trade dispute? Yes How long have you or your partner
We use trade dispute to mean a strike, not been working because of a
a walkout, a lockout or another dispute at work. trade dispute?
If this is less than 6 weeks, we may not
be able to make a payment.
3
Part 3 If a baby is expected

Please tell us the date the baby is expected / / For office use
So that we can consider your claim for a Sure Start Maternity Grant,
the certificate (SSMG cert) which is on the back page of this claim SSMG cert received No
form must be filled in by a health professional. For example, Yes
your midwife.
Other approved docs No
Is more than one baby expected? No Yes
Yes How many babies are expected?
Initials .................................
Date ......... / .......... / ...........
Please make sure that the document you are
sending with this claim form tells us the
number of babies that are expected.

If the baby has not been born yet, now

go to Part 6.

Part 4 If the baby has already been born

Please tell us the date the baby was born

For office use
/ /
So that we can consider your claim for a Sure Start Maternity Grant, SSMG cert received No
the certificate (SSMG cert) which is on the back page of this claim
form must be filled in by a health professional. For example, Yes
your midwife.
Other approved docs No
In case of a still birth you do not have to send the certificate
(SSMG cert) but, so that we can consider your claim, you must Yes
provide us with evidence of the birth.
Initials .................................
Date ......... / .......... / ...........
Was more than one baby born? No
Yes How many babies were born?

4
Part 5 About a baby already born that you have become responsible for

Are you the parent, but not the mother, No

of a baby you now care for? Yes When did the baby start to live with you?
/ /

When did you get Child Benefit?

/ /

Who got the Child Benefit before?

Have you or your partner been granted an No

adoption order or a residence order? Yes What is the date of the order?
/ /

For how many children?

Please send the order with this claim form.

Have you and your partner been granted a No

parental order under section 30 of the Yes What is the date of the order?
Human Fertilisation and Embryology Act or
section 54 of the Human Fertilisation and / /
Embryology Act 2008?
For how many children?

Please send the order with this claim form.

5
Part 5 About a baby already born that you have become responsible for

Have you or your partner been appointed a No

legal guardian? Yes What date did this take effect?
/ /

For how many children?

Please send the evidence of appointment with this claim form.

Have you or your partner had a child No

placed with you for adoption? Yes What date was the placement?
/ /

How many children were placed?

Please send the evidence of placement with this claim form.

Have you or your partner adopted a baby No

from overseas? Yes What date did this take effect?
/ /

How many children were adopted?

Please send evidence that the adoption is recognised in Great Britain

with this claim form.

6
Part 6 About other children under 16 in your household

Apart from the baby you have told us about in No Go to Part 7.

Part 3, Part 4 or Part 5, are there any other Yes Tell us about the children below. If you need to tell us about more than 4 children,
children under the age of 16 in your household? please use the space in Part 9.
Please note there is an exception to the child You cannot get a grant unless your new baby is the only child under 16 in your
under 16 rule in the case of multiple births.
family, or your dependant’s new baby is the only baby under 16 in your family.

Name of child Date of birth Relationship to you or Benefits or tax credits you or
your partner your partner get for the child

Part 7 General information

Has a Sure Start Maternity Grant from the No
Social Fund already been paid to either you or
someone else for this baby or babies? Yes Who was it paid to?

We can only pay another Sure Start Maternity Grant if:

● you are not the mother but have become the parent who cares for the baby
● you have been granted an adoption or residence order, or
● you and your partner have been granted a parental order under section 30 of the
Human Fertilisation and Embryology Act 1990 or section 54 of the Human Fertilisation and
Embryology Act 2008
● you have been appointed the guardian
● you have had a baby placed with you for adoption by an agency
● you have adopted overseas within section 66(1)(c)–(e) of the Adoption and Children Act 2002.

Are you or your partner already getting No If you want to claim Child Benefit, claim forms are available direct
Child Benefit? from HM Revenue & Customs. Phone the Child Benefit helpline on
Yes 0300 200 3100 or visit www.hmrc.gov.uk

7
Part 8 Making payments to you

We normally pay your money direct into an account

Many banks and building societies will let you collect your money at the post office. We will tell you when
your Social Fund payment will be made and how much it will be for.

Finding out how much we have paid into the account

You can check your payments on account statements. The statements may show your National Insurance
(NI) number next to any payments we have made. If you think your payment is wrong, get in touch with the
office that pays you straight away.

If we pay you too much money

We have the right to take back any money we pay that you are not entitled to. This may be because of the
way the system works for payments into an account. For example, you may give us information which
means you are entitled to less money. Sometimes we may not be able to change the amount we have
already paid you. This means we will have paid you money that you are not entitled to.
We will contact you before we recover any money.
What to do now
● Tell us about the account you want to use on the next page. By giving us your account details you:
– agree that we will pay you into an account, and
– understand what we have told you above in the section If we pay you too much money.
● If you are going to open an account, please tell us your account details as soon as you get them.
● If you do not have an account, and do not intend to open one, please tick the box and we will contact you.

Fill in the rest of this form.

You do not have to wait until you have opened an account or contacted us.

8
Part 8 Makingyou
About payments topartner
and your you continued

About the account you want to use

Please tell us your account details below. It is very important you About the account you want to use
complete ALL boxes correctly including the building society roll or You can use
reference number if you have one. If you tell us the wrong account ● an account in your name
details your payment may be delayed or you may lose money. ● a joint account, or
You can find the account details on your chequebook or bank ● someone else’s account,
statements. If you are not sure about the details, ask the bank, building – subject to the terms and conditions of the account, and
society or other account provider. – as long as you have the other person’s permission and authorise them to
use the money in the way you tell them.
● If you are an Appointee or a legal representative acting on behalf of the
claimant, the account should be in your name only.
● To be paid into a credit union account you must provide the credit union’s
account details. Your credit union will be able to help you with this.

Name of the account holder

Please write the name of the account holder exactly as it is shown
on the chequebook or statement.

Full name of bank, building society, Post Office or other account provider

Sort Code
Please tell us all six numbers, for example: 12-34-56.
Account number
Most account numbers are 8 numbers long. If your account number has
fewer than 10 numbers, please fill in the numbers from the left.

If you are using a building society account you may need to tell us a roll or
reference number. This may be made up of letters and numbers, and may
be up to 18 characters long. If you are not sure if the account has a roll or
reference number, ask the building society.

Building society roll or reference number

You may be getting other benefits and entitlements that are not paid direct
into an account. To have them paid into the above account, please tick the box.

9
 Part 9 Other information

You can use this space to tell us anything else you think we might need to know.
If there is not enough space, please use a separate sheet of paper. Make sure that you put
your full name and National Insurance (NI) number on it.

10
Part 10 For people filling in and signing this form for someone else
Have you filled this form in for someone else? No Go to Part 11.
Yes Please tell us about yourself.
Please tell us why you are filling in and signing I am sending a letter signed by Now sign this form in Part 11.
this form for someone else. the claimant with this form.
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
What is this number? Home Work Mobile Fax
Please tick
Now sign this form in Part 11.

11
 Part 11 Declaration

I declare that the information I have given on this form is correct and complete as far as I know and believe.
I understand that if I knowingly give information that is incorrect or incomplete, my benefit may be stopped and 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.

This is my claim for a Sure Start Maternity Grant.

Signature Date / /

Part 12 What to do now

● 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.
● You must send us this form within 3 months of the date
● Check that the health professionals’ statement has been completed – you become the responsible parent of the baby if you are not
by your midwife, or other health professional. the mother
● Check that you are sending all the documents we have asked for. – of an adoption, residence or parental order
Please send the originals as we cannot accept photocopies. But do – the guardianship takes effect
not delay sending in this form. – the baby is placed with you for adoption
– the overseas adoption takes effect or is recognised.
● Send or take this form to Jobcentre Plus. You can find the address in
the business section of the phone book. Look under Jobcentre Plus. But remember, you must claim before the baby is more than
12 months old.

Part 13 What happens next

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.
Do not delay.
The time periods for claiming are on the back of the Notes at the front of this claim form.

12 Printed on recycled paper

 Health professional’s statement SSMG (cert)
To be completed by the health professional only

I certify that ............................................................................... (insert name of parent)

l consulted me in respect of ...................... (insert words and number. For example: 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 or health visitors who

Health professional’s name (please print or use a stamp) do not have an authentication stamp, details of surgery or
office address and telephone number, contact telephone
number if different, and UKCC PIN.

▼
Tear off here

SF100_042014_016_001