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A. PARENT / GUARDIAN DETAILS
Last name*First names*
Title
Date of birth*
National insurance number* or NASS number
Address
Postcode / If the sections marked with an * are not complete we will not be able to check your entitlement.
Telephone number
B. YOUR CHILDREN
Give details of all the children in the family aged under 5 years of age.
First name / Last name / Date of birth / Boy/Girl / Childcare provider (if known) / Your relationship to this childC. DECLARATION
I declare that the information I have given in this form is true and complete and I undertake to inform Lewisham if my benefit entitlement changes. I agree to Lewisham contacting other sources as allowed by the law to verify my initial, and ongoing entitlement.
I further authorise that the data on this form may be held on a computer system which has been registered in accordance with the Data Protection Act 1998 and may be shared with other local and national government agencies in order to facilitate the processing of this or other applications for assistance.
Signature / DateD. DWP BENEFITS / INLAND REVENUE TAX CREDITSWhich benefits / tax credits do you receive?
Tick boxIncome support or Job Seeker’s Allowance(Income-based)
Employment Support Allowance (Income-related)
Child Tax Credit only –household income is no more than £16,190
Working Tax Credits - household income is no more than £16,190
Guarantee Element of Pension Credit
Support under part VI of the Asylum Act 1999
General information
We will use the information you have provided on this form to check your entitlement to the 2 Year Old Early Learning Entitlement Offer. If we cannot verify your entitlement we will contact you to request further information.
Your child will continue to receive the 2 Year Old Early Learning Entitlement Offer regardless until they transfer to the universal 3 & 4 Year Old Free Entitlement Offer.
How to contact us
Post
Student & Pupil Support
3rd Floor
Laurence House
Catford
SE6 4RU
2YO Free Entitlement App FormJuly14.docSep2014