Assisted Person Vists Application Form Page 2
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4PART 2 - ABOUT YOUR INCOME
I, OR THE PERSON WHO CLAIMS BENEFITS FOR ME:
Receive/s INCOME SUPPORT
Receive/s JOBSEEKERS ALLOWANCE (INCOME BASED)
Receive/s EMPLOYMENT AND SUPPORT ALLOWANCE (INCOME RELATED)
The original Universal Credit award notice must be included
Receive/s UNIVERSAL CREDIT
with this form. Note - a maximum income limit applies
The original Tax Credit award notice must be included with
Receive/s WORKING TAX CREDIT
(with disability element)
this form. Note - a maximum income limit applies
The original Tax Credit award notice must be included with
Receive/s CHILD TAX CREDIT
this form. Note - a maximum income limit applies
The original Pension Credit award notice must be included
Receive/s PENSION CREDIT
with this form.
The original Health Certificate notice must be included with
Hold/s a HEALTH CERTIFICATE - HC2
this form.
The original Health Certificate notice must be included with
Hold/s a HEALTH CERTIFICATE - HC3
this form.
If someone else claims benefits for you please give their name and National Insurance Number.
Name
National Insurance Number
Note - if you have not ticked any of the boxes in this section you will not qualify for assisted prison visits.
PART 3 - ESCORTS
I am escorting an adult
(complete below)
Someone else’s child/children
(complete below)
My child/children
go to Part 4
Give details of the adult you are escorting or details of the parent/carer of the child/children you are escorting
Their name
Their address
Postcode
National Insurance Number
Date of birth
Note:
Escorting Someone Else’s Child/Children
Before we can deal with your claim the parent/carer of the child/children you are escorting
must write to us to authorise the visit and provide details about their income.
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