Applying for ALG - An Introduction by JamieGribowicz

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									                            Application for Adult Learning Grant
                               ALG Year 01/09/08 – 31/08/09




 Applying for ALG - An Introduction
  Applicants for ALG should read this page before applying
•	 You must be at least 19 years old
•	 Your course must start or continue between the dates 01/09/08 and 31/08/09
•	 You must be intending to study in England – see guidance notes page 6

You must be studying full time
•	 Full time means at least 450 hours of guided learning per year, or 150 hours of guided learning per
   term. For example, if you study 12 hours a week for 38 weeks, this would count as studying full time
•	 Guided learning means someone is helping you learn. It could mean you are sitting in the classroom,
   attending a lecture or being supervised.

You must be studying for your first full Level 2 or your first full Level 3 qualification. For example:
•	 a full Level 2 qualification could be 5 GCSE’s at grades A* to C or an NVQ2 or equivalent
•	 a full Level 3 qualification could be 2 A Levels, or an NVQ3 or equivalent
You may have some of these qualifications but have not yet completed enough to have earned the full
level. For further details see guidance notes page 10.

      Important – To get ALG you must meet the residency conditions on pages 6-9 of the
                   guidance notes; read these before completing this form.
             If you DO NOT meet these conditions DO NOT apply for ALG.
•	 You will be assessed on your income for the previous tax year (2007-08). If you live alone or with
   parents your personal income must be £19,513 or less. If you live with your parents, we will only
   take into account your personal income, not theirs
•	 If you are married or live with a partner, as if you are married, your joint income must be £30,810
   or less
                                                               Continued overleaf


ALG 1
If you get ALG, you can still receive:

•	 Help	with	hardship,	childcare	and	residential	costs,	Career	Development	Loan	(you	cannot	use	
   a	Career	Development	Loan	to	pay	for	anything	funded	by	the	Adult	Learning	Grant),	Carers	
   Allowance,	Housing	Benefit,	Council	Tax	Benefit,	Tax	Credits	and	Child	Benefit.	

To get ALG, you must not be receiving:

•	 Support	from	Education	Maintenance	Allowance	(EMA),	New	Deal	or	an	Apprenticeship
•	 Benefits	such	as	Jobseeker’s	Allowance,	Income	Support,	or	Incapacity	Benefit
   (You must come off these before you can get ALG. See guidance notes page 13).

•	 If you are in a prison or young offender institution or have been released on temporary license
   (ROTL)	you	are	not	eligible	to	claim	ALG.	However,	you	may	apply	for	the	scheme	whilst	serving	
   your sentence once your expected release date is known. No ALG payments will be made until
   after release, and then only if the eligibility conditions are met.
•	 If you have been released from prison or a young offender institution or you remain under
   supervision (including if you are electronically tagged) in the community, you can apply for ALG.

•	 You	will	need	a	Bank/Building	Society	account	that	accepts	BACS	payments.

Send your completed form and evidence to us as soon as you can. If we receive your application
within 28 days of you starting your learning programme, you may be entitled to receive payments
from the start of your learning programme. ALG payments cannot be made until you give your
Notice of Entitlement (NoE) to your Learning Provider.

     Filling in this form

•		To help you, brief notes are given at each question and more help is available in the guidance notes
•	 Please	fill	in	the	form	using	BLACK INK and in CAPITAL LETTERS
•		You can also call us for more help on 0800 121 8989 between 07:00 and 20:00
				Monday	to	Friday.		Alternatively,	visit	our	website	www.direct.gov.uk/alg



This ALG Application pack contains:

•	 Application	Booklet	(Parts	A,	B	and	C),	Part	C	can	be	torn	off	for	completion	by	your	benefits	office
•	 Guidance Notes to help you fill in the form
•	 Pre-paid reply envelope




ALG 2
    Part A - Your Details
    If we posted the form to you and your details are printed on the introduction sheet and are correct, you do
    not need to fill in questions A1 to A3. If any of those details are wrong, please fill in questions A1 to A3 in full.

A1          Your name
                             Mr                 Miss                Mrs                   Ms             Other
Surname/family name
First name(s)

A2          Your address
House/flat	no./name	
Street or Road
District	
Town/City
County                                                                                       Postcode
A3          Date	of	birth
                                   D D          M M          1 9 Y Y

A4          Your contact details
Home	phone
Mobile	phone
Email
                  @
A5          Contacting you

If we need to contact you about your application, how should we contact you?
	       												Email	             						Mobile	phone																									Home	phone	   																	Post

A6	 How	did	you	first	hear	about	Learner	Support	Schemes?	Mark	one	box	only
(Adult	Learning	Grant,	Education	Maintenance	Allowance,		6th	Form	College	Childcare	or	Care	to	Learn)
              Internet                  Radio                      Television                 Press adverts
		      	           Bus/banner	advert	               Leaflets	or	posters	           Friend	or	family	                   School
                    FE college                       Connexions                     Nextstep                            Learndirect
                   Other learning provider           Support worker

A7          Equal opportunities monitoring
    The answers you give here will help us to make sure we are reaching all parts of our community.Your
    answers will not affect your assessment and if you prefer, you can choose to leave this question blank.

Are	you:	                          	                 	              	               Male		          		                  Female	
Do	you	consider	yourself	to	have	a	disability?                                      Yes                                 No
    If you are not sure if this applies to you, page 6
    of the guidance notes will help you.                                    BARCODE	goes	here

ALG 3
A7 Equal opportunities monitoring (continued)
How	would	you	describe	your	ethnic	origin?
White                                     Black or Black British
      British	                                  African
      Irish                                     Caribbean
      Any other white background                Any other black background
Mixed                                     Asian or Asian British
      White and black Caribbean                 Indian
      White and black African                   Pakistani
      White and Asian                           Bangladeshi
      Any other mixed background                Any other Asian background
Chinese or other ethnic group
      Chinese                                   I do not wish to record my ethnic group
      Any other
A8    Residency conditions
   To	qualify	for	ALG,	or	any	other	Learner	Support	Scheme	(EMA,	6th	Form	College	Childcare	or	Care	to	
 Learn) you must meet the residency conditions set out in guidance notes pages 6-9; read those carefully and
                        then mark one box only for the condition which applies to you.
A        I am a person who is settled* in the UK, and have been ordinarily resident in the UK for at least three
         years prior to the start of my learning programme
* ‘Settled’ means having either indefinite leave to enter or remain (ILE/R), or having right of abode in the UK.
  British	citizens	and	certain	other	people	have	the	right	of	abode	in	the	UK	(see	guidance	notes	pages	6-7)
B       I am a national of any European Union (EU) country (including Gibraltar) or the spouse or civil
        partner or child of an EU national, and have been ordinarily resident in the European Economic Area
      	 (EEA)	or	Switzerland	for	at	least	three	years	prior	to	the	start	of	my	learning	programme
C       I am an EEA migrant worker who has the right to work in the UK, or the spouse or civil partner
        or child of an EEA migrant worker, who has been ordinarily resident in the UK at the start of my
        learning programme, and have been ordinarily resident in the European Economic Area (EEA) or
      	 Switzerland	throughout	the	three	years	prior	to	that.	If	you	are	the	child	of	a	Swiss	national,	or	the		
        child of a Turkish migrant worker, please see guidance notes pages 6-9
D       I am recognised as a refugee by the UK Government, or the spouse or civil partner or child of a
      	 refugee,	or	have	been	granted	Humanitarian	Protection,	or	have	EU	Temporary	Protection.

     Important - If you DO NOT meet these conditions, DO NOT apply for a Learner Support Scheme.
                Please call us on 0800 121 8989 for more help about residency conditions.

A9    Your learning
When do you intend to start your course?                    D D     M M        2   0   0   Y


 If you don’t know when your course will start, see guidance notes page 10.




ALG 4
A10 Your learning achievements

Tell us, by marking the boxes below, what educational qualifications you have achieved. If you need help with
this, see pages 10-11 of the guidance notes.
        Any	Degree	or	higher	(UK	or	Overseas),	
        Teaching	Qualifications
        Access	to	HE
        NVQ level 5
        NVQ level 4
        NVQ level 3
        NVQ level 2
        NVQ level 1
        International	Baccalaureate
        GNVQ Advanced
        GNVQ Intermediate
        GNVQ Foundation

        BTEC	Higher	National	Certificate/Higher	
        National	Diploma
        BTEC	National	Certificate/National	Diploma
        BTEC	First	Diploma
        BTEC	National	Award
        BTEC	Introductory	Diploma
        BTEC	Certificate/Diploma
        AVCE,	VCE	or	Vocational	A	level	Double	Award
        AVCE,VCE or Vocational A level Single Award
        ONC
        OND

For the following qualifications, tell us if you have them and how many you have.
        A	level	            	             	             How	many?
        AS	level	           	             	             How	many?
        O	level/GCSE	at	grade	A*	to	C		 	               How	many?
        O	level/GCSE	at	grade	D	to	G	 	                 How	many?
        CSE Grade 1                                     How	many?
        CSE	Grade	2	to	5	 	               	             How	many?
        Other (including OCR/RSA/City and Guilds Qualifications and Overseas Qualifications), please give
        details in the box below, and send us a copy of your certificate(s) with your application



        I have no qualifications
ALG 5
A11 Previous ALG payments

If you received ALG payments at any time between September 2007 and August 2008, mark this box
We will make payments into the same account as we did in 2007/08 unless you contact us on 0800 121 8989
If you know your ALG number, fill in this box

  If you marked the box, you do not need to fill in question A12 and you do not need to send us a bank
  statement or other bank evidence. If you did not mark the box, go to question A12.


A12 Your	Bank	or	Building	Society	account	details

   You must enclose an original bank statement, letter or form from your bank that shows your name,
    sort code, account number, roll number (if applicable) and home address. If for some reason the
  address on your evidence is different from the address on your application form, you must tell us why.

  To receive ALG payments, you must normally have a bank account in your own name that we can make
  payments	into.	If	you	do	not	have	a	bank	account,	you	need	to	open	one	first	and	then	fill	in	this	form	when	
  you have the information we need. If you are unable to administer your own bank account, please call us on
  0800 121 8989.

Full name of account holder
Name	of	Bank/Building	Society
Branch

Sort Code
                                                                     Your bank account number may not be the same as the cash or
Account Number                                                       debit card number.You can find it on a statement or cheque book.

Roll Number (if applicable)                                                                       Roll numbers only apply to
                                                                                                  some	Building	Society	accounts.




A13 Your personal circumstances
Are you married, in a civil partnership or living with someone as if you are married? Yes                       No

 If you answered YES, we need to know about your and your spouse or partner’s income.You and your
 partner/spouse	must	complete	Part	B	and,	if	appropriate,	Part	C	of	this	form.	See	guidance	notes	page	12
 for more help on income assessment.




ALG 6
Part B - Income Details                               Office use only
                                                      ALG number:           M             Y


If you answered YES to A13, we need the income and personal details for both yourself and your spouse or
partner for the tax year 6 April 2007 to 5 April 2008.

B1 Spouse or partner details

Surname/family name
First name(s)

Relationship to                  Spouse              Partner
applicant for ALG


B2 National Insurance Number
Your NI Number
Partner/Spouse NI Number


B3   If at the time of applying for ALG your income and that of your partner/spouse (if you have one) is
	                                                	
     lower	than	your	income	in	2007-08	due	to	disability,	as	defined	by	the	Disability	Discrimination	Act,		
     read the guidance notes pages 13-14 for help.


Your income and your partner’s/spouse’s income (if you have one)
If you or your partner/spouse received any income in the tax year 2007-08, you need to tell us below how
much you received. If you have a Tax Credit Award Notice (TCAN), and this gives the income details
for you and/or your partner/spouse, go straight to B10 and see page 22 in the guidance notes.

Before	you	complete	this	part	of	the	application,	check	the	guidance	notes	for	help	on	what	income	you	
need to include in each box. State the amount you received and send us the evidence requested where we
have asked for it. Round your answers down to the nearest pound and do not include pence.

 Questions B4 to B6 are about income from employment


                                             Applicant                  Partner         Evidence required
B4 Write in your total taxable
                                                                                    You need to send us any P60 or
   pay as an employee from all £                               £                    P60U forms you have for the
   jobs before taking off Tax and                                                   tax year 2007-08.
   National Insurance contributions
B5 Write in the value of any                                                        You	need	to	send	us	any	P9D	or	
   employer benefits in kind,      £                           £                    P11D	forms	you	have	from	your	
   eg company car benefits, payment                                                 employer for the tax year
   of bills or taxable vouchers                                                     2007-08.


                                                                                    You need to send us your form
B6 Write in the total taxable                                                       SA302 for the tax year 2007-08
   income from                         £                       £                    or call us on 0800 121 8989 if you
   self employment                                                                  do not have one.




ALG 7
Question B7 is about other income


B7 Work out the total for both adults of any other income, including pensions, over £300 using the
     table below.
Annual amount of:                          Applicant            Partner
Interest from savings and investments
Income from property                                                            For income paid in a foreign
                                                                                currency, state the equivalent
Trusts, settlements and estates                                                 in pounds sterling.
Foreign income
Pensions (state, occupational or personal)
Notional income
Add together the totals
Totals                                                  +                           =
Deduct	£300                                                                                      – 300
Total other income (round down to the nearest pound)                                                 £
Questions B8 and B9 are about your allowable deductions

B8   Write in any personal               £                           £
     pension contributions you
     paid direct. Enter the gross    If you paid your pension contributions through your employer, you do not have to fill in
                                     this box. Your employer will already have deducted your pension contributions from the
     figure before any tax relief.   pay figure entered on your P60 or P45.

B9 If, during the tax year, either adult received
   Statutory Maternity Pay, Statutory Paternity
                                                                     £
   Pay or Statutory Adoption Pay, multiply the
   number of weeks by £100 and put the total in the box.
If your current income is significantly lower than 2007/08 declared income above, please call us on 0800 121 8989
for help and see guidance notes page 5.

B10 If you have a Tax Credit Award Notice (TCAN) form TC602 that correctly states your income and
    that of your partner/spouse (if you have one) for the tax year 2007-08 put the amount in this box.
Before	you	answer	this	question,	read	the	information	about	TCANs	on	page	22	of	the	guidance	notes.
                                             Write your total income, as shown on the Tax Credit Award
     £                                       Notice.	Round	down	to	the	nearest	pound.	Do	not show pence.
                                             For example: £ 1 5 0 0 0

Now go straight to the declaration at B13. Do	not	fill	in	Part	C.	You	have	completed	your	application.	You	must	
enclose the original Tax Credit Award Notice with your application.

B11	 Did	you	and/or	your	partner/spouse	receive	any	of	the	following	benefits	for	part	of,	or	the	whole	of,	
     the tax year 2007-08?
Income	Support,	Pension	Credit,	Carer’s	Allowance,	Contributions-based	Jobseeker’s	Allowance,
Income	based	Jobseeker’s	Allowance,	Incapacity	Benefit,	or	Bereavement	Allowance
                   Applicant                           Partner

                   Yes         No                      Yes           No
If either you or your partner/spouse answered YES to the question above, you must complete Part
C and send it to the office that deals with your benefits. Return Part C to us when it has been
completed.
You	cannot	receive	ALG	with	Income	Support,	Jobseeker’s	Allowance	or	Incapacity	Benefit.	If	you	are	
currently on these benefits you must stop receiving them before you claim ALG.

ALG 8
B12	Did	you	and/or	your	partner/spouse	receive	any	of	the	other	kinds	of	income	listed	on	page	24	of	the	
    guidance notes for part of, or the whole of the tax year 2007-08?
                   Applicant                        Partner

                   Yes         No                   Yes         No

If either you or your partner/spouse answered YES	to	question	B12 above, check page 24 of the guidance
notes and tell us how you were financially supported in the boxes below. If either of you were supported
financially, for example - by parents or maintenance from an ex-partner, you must include this in the boxes
below as well.
 Applicant




 Partner/Spouse




B13 Data Protection Statement and ALG Applicant and Partner/Spouse Declaration

Data Protection
The information you provide on this form will be passed to the Learning and Skills Council (the LSC). The
LSC is responsible for funding, planning and encouraging education and training for over 16-year-olds in
England,	and	is	registered	under	the	Data	Protection	Act	1998.	The	information	you	provide	will	be	shared	
with other organisations for administration and statistical purposes. Other organisations with which we will
share	information	include	the	Department	for	Children	Schools	and	Families,	the	Department	for	Innovation	
Universities	and	Skills,	Connexions,	Higher	Education	Statistics	Agency,	Higher	Education	Funding	Council	
for England, UCAS, Student Loans Company, educational institutions and organisations performing research
and statistical work on behalf of the LSC or its partners. The LSC is also a co-financing organisation and uses
European Social Funds from the European Union to directly or indirectly part-finance learning activities,
helping develop employment by promoting employability, business spirit and equal opportunities, and investing
in human resources.
Further information about partner organisations, and what they do, may be found at www.lsc.gov.uk
At no time will your personal information be passed to organisations for marketing or sales purposes.
ALG Applicant Only
Mark	this	box	if	you	DO NOT wish us to tell the person named as your partner/spouse                     A
(named	in	B1	of	Part	B	of	this	form)	about	the	progress	of	your	application	and	payments.
At no time will your personal information be passed to organisations for marketing or sales purposes.
From time to time students are approached to take part in surveys by mail and phone, which are aimed
at enabling the LSC and its partners to monitor performance, improve quality and plan future provision.
Mark	this	box	if	you	DO NOT wish to be contacted by the LSC or its partners in respect of surveys B
and research. The LSC values your views on the education or training which you receive, and will use
these to help bring about improvements for learners aged over 16 in England.
The LSC or its partners may wish to contact you from time to time about courses, or learning            C
opportunities relevant to you. Please mark this box if you DO NOT wish to be contacted about
courses or learning opportunities by post.
ALG 9
   Important – You are not required to sign and date this application, however by submitting this form in
   support of an application for ALG you and your partner/spouse (if you have one) are agreeing to all the
                                      statements and conditions below.


ALG Applicant and Partner/Spouse Declaration
If you give false or incomplete information, or if you and your partner/spouse (if you have one) do not tell
us about any part of your income that is relevant, you may be prosecuted. As part of our assessment process
we will sample application forms and may ask for further evidence. If that evidence is not provided, or
results in a lower award being due, we may stop any future payments and seek repayment of anything paid.

I/We have read and understood the guidance notes supplied with this form including the
Data	Protection	Statement.	

I/We declare that all information given in support of this application is correct and complete to the best
of my/our knowledge and belief.

I/We understand that:
 •	 I/We share responsibility for the information given with any partner/spouse named on this form
 •	 if the person applying for ALG with this form does not keep to their ALG Agreement, or if they leave
    their learning programme, they will not be eligible to receive further payments and any ALG overpaid may
    be recovered
 •	 the information I/we have given may be shared with other agencies or organisations, as allowed by law,
    for the purposes of checking this application and/or the prevention of fraud
 •	 the applicant is eligible for ALG on residency grounds as explained on pages 6-9 of the guidance notes
    and can provide suitable evidence as proof when enrolling on their learning programme.

ALG Applicant only A
I understand that:
•	 I	am	not	allowed	to	receive	ALG	payments	at	the	same	time	as	any	other	government	training	or	
   learning allowance
•	 I	am	not	allowed	to	receive	Jobseeker’s	Allowance,	Income	Support	or	Incapacity	Benefit	at	the	same	time	
   as ALG.
Please ensure you have…
    enclosed original evidence of your bank account that shows: your name, home address, account number,
    sort code and roll number (unless you currently receive ALG and will continue to use the same account)
    included any income from you and your partner/spouse (if you have one) for the tax year 2007-08 in
    parts	B	and	C
    enclosed income evidence for 2007-08 for you and your partner/spouse

    listed the benefits received in 2007-08 on Part C and had this confirmed by your
     benefits office (if applicable)




ALG 10
                                                                                                Office use only
                       Part C - ALG Applicant                                                   ALG number:              M                  Y

                       	 	 		Benefits
                       Fill in your details on this page if you received social security benefits between 6 April 2007 and 5 April
                       2008 (Tax year 2007-08). If this applies to your partner/spouse as well, use the other side of this form.
                       When you have filled in your details, send it to the office that normally deals with your benefit payments.
                       When Part C has been returned to you, send it to us at: Freepost	RRUB-BEXE-TJLK,	Learner	Support	
                       Service,	Darlington	DL1	4WD
                        The Applicant
                       Surname/                                                                  First name
                       family name
                       National Insurance number
                        Address
                        I	authorise	the	Department	for	Work	and	Pensions	to	disclose	information	
                                                                                                       Sign here
                        regarding my benefits and allowances for the purposes of assessing an
                        application for Adult Learning Grant. You cannot receive ALG with
                        Income	Support,	Jobseeker’s	Allowance	or	Incapacity	Benefit.	If	you	are
                        currently on these benefits you must stop receiving them before you claim ALG.

                                         For DWP office use only – the applicant must not write below this line
                       C1 The	person	named	above	was	in	receipt	of	Income	Support,	Income-based	Jobseeker’s	Allowance	or	Pension	
                          Credit during the tax year 2007-08.
tear along this line




                           Yes, for the whole year                    Do not fill in any further questions. Now sign and date the declaration overleaf.
                                                                                            From (date)                  To (date)
                                                                                                                                                   Now complete
                           Yes, for part of the year – fill in start                D D M M Y Y                   D D M M Y Y                       question C2 if
                           and end dates in boxes provided                                                                                          applicable and
                                                                                    D D M M Y Y                   D D M M Y Y                     sign and date the
                                                                                                                                                 declaration overleaf.

                       C2 The person above was in receipt of other benefits during the tax year 2007-08 as follows:
                                                                                            From (date)                  To (date)                   Weekly rate

                       Carer’s Allowance (incl.	any	CDI	elements)                   D D M M Y Y                   D D M M Y Y                   £ £ £ £ . p p

                       Contributions-based	Jobseeker’s	Allowance
                       (excluding	any	amounts	of	JSA[IB])                            D D M M Y Y                  D D M M Y Y                   £ £ £ £ . p p

                       Incapacity benefit – short	term	higher	rate	–	gross	amounts	including	any	CDI	elements.	
                       Exclude	Incapacity	Benefits	which	started	
                       prior to 13 April 1995.                                       D D M M Y Y                  D D M M Y Y                   £ £ £ £ . p p

                       Incapacity benefit – long	term	higher	rate	–	gross	amounts	including	any	CDI	elements.	
                       Exclude	Incapacity	Benefits	which	started	
                       prior to 13 April 1995.                                       D D M M Y Y                  D D M M Y Y                   £ £ £ £ . p p

                       Bereavement	Allowance	                                       D D M M Y Y 	 D D M M Y Y 	                                 £	 £ £ £ . p p
                       If the person claimed any of the above benefits for more than one period write in the type of benefit, the period(s) of the claim and the weekly
                       rate.

                                                                                    D D M M Y Y                   D D M M Y Y                   £ £ £ £ . p p
                                                                                    D D M M Y Y                   D D M M Y Y                   £ £ £ £ . p p
                                                                                    D D M M Y Y                   D D M M Y Y                   £ £ £ £ . p p

                                Now check the other side of this page, for applicant’s partner/spouse (if applicable).
                         DWP Officer: please check other side of the form and sign and date the declaration overleaf

                       ALG 11
Part	C	-	Partner/	Spouse	Benefits
 Fill in your details on this page if you received social security benefits between 6 April 2007 and 5 April 2008
 (Tax year 2007-08).

 Partner/Spouse of ALG Applicant
 Surname/                                                                      First name
 family name
 National Insurance number
 Address
 I	authorise	the	Department	for	Work	and	Pensions	to	disclose	information	
                                                                                                Sign here
 regarding my benefits and allowances for the purposes of assessing an
 application for Adult Learning Grant.


                   For DWP office use only – the applicant must not write below this line
C3 The	person	named	above	was	in	receipt	of	Income	Support,	Income-based	Jobseeker’s	Allowance	or	Pension	
      Credit during the tax year 2007-08.
      Yes, for the whole year                Do not fill in any further questions. Now sign and date the declaration overleaf.
                                                                 From (date)              To (date)
                                                                                                                  Now complete
      Yes, for part of the year – fill in start            D D M M Y Y              D D M M Y Y                   question C4 if
      and end dates in boxes provided                                                                             applicable and
                                                           D D M M Y Y              D D M M Y Y                 sign and date the
                                                                                                                declaration below.




                                                                                                                                                   tear along this line
C4      The person above was in receipt of other benefits during the tax year 2007-08 as follows:
                                                                       From (date)                To (date)                   Weekly rate

Carer’s Allowance (incl.	any	CDI	elements)                    D D M M Y Y                  D D M M Y Y                 £ £ £ £ . p p

Contributions-based	Jobseeker’s	Allowance
(excluding	any	amounts	of	JSA[IB])                            D D M M Y Y                  D D M M Y Y                 £ £ £ £ . p p
Incapacity benefit – short	term	higher	rate	–	gross	amounts	including	any	CDI	elements.	
Exclude	Incapacity	Benefits	which	started	
prior to 13 April 1995.                                       D D M M Y Y                  D D M M Y Y                 £ £ £ £ . p p

Incapacity benefit – long	term	higher	rate	–	gross	amounts	including	any	CDI	elements.	
Exclude	Incapacity	Benefits	which	started	
prior to 13 April 1995.                                       D D M M Y Y                  D D M M Y Y                 £ £ £ £ . p p


Bereavement	Allowance	                                        D D M M Y Y 	 D D M M Y Y	                               £	 £ £ £ . p p
If the person claimed any of the above benefits for more than one period write in the type of benefit, the period(s) of the claim and the weekly
rate.

                                                              D D M M Y Y                 D D M M Y Y                  £ £ £ £ . p p
                                                              D D M M Y Y                 D D M M Y Y                  £ £ £ £ . p p
I confirm the benefit details entered on the previous page and, if applicable, above.
DWP	officer	
initial and surname


DWP	officer	sign	here                                                                                    DWP office stamp here


                                      DDD            MMM           2     0Y0         Y

             Now sign and stamp the form and return to the ALG applicant named overleaf
ALG 12
                                                        Office use only
Part D – ALG Applicant                                  ALG number:         M            Y

and Partner/Spouse
Income from self-employment
D1 About you and your partner/spouse (if you have one)
                                         Applicant                              Partner/Spouse
Surname/family name
First name(s)
Tax reference


D2 Details	of	income	for	tax	year	(you	must	mark	the	appropriate	tax	year	box)
   2007-08                       2006-07                Applicant          Partner/Spouse
Employment	income	and	Directorships	             	£ £ £ £ £ £             £ £ £ £ £ £
Self-Employment (as a sole trader)                   £ £ £ £ £ £          £ £ £ £ £ £
Partnerships                                         £ £ £ £ £ £          £ £ £ £ £ £
UK Land and Property                                 £ £ £ £ £ £          £ £ £ £ £ £
UK Interest (before tax)                             £ £ £ £ £ £          £ £ £ £ £ £
UK	Dividends	and	tax	credits	                        £ £ £ £ £ £          £ £ £ £ £ £
UK Pensions and benefits                             £ £ £ £ £ £          £ £ £ £ £ £
Other taxable income                                 £ £ £ £ £ £          £ £ £ £ £ £
Total income received
(before tax taken off)                               £ £ £ £ £ £          £ £ £ £ £ £



D3 Deductions	allowable	for	tax	purposes	(the	Personal	Allowance	is	not	deductible)
                                                        Applicant          Partner/Spouse

Retirement annuity or personal pension               £ £ £ £ £ £          £ £ £ £ £ £
Losses from previous year                            £ £ £ £ £ £          £ £ £ £ £ £
Other                                                £ £ £ £ £ £          £ £ £ £ £ £
(you must specify or your form will
be returned)
Total allowable deductions
for tax purposes                                     £ £ £ £ £ £          £ £ £ £ £ £


Total	(D2	minus	D3)	                                 £ £ £ £ £ £          £ £ £ £ £ £




ALG 13
 D4 Declaration	by	Accountant	(the	Personal	Allowance	is	not	deductable)
 (this section is to be completed by your Accountant if he or she has provided information)
 I certify that the information I have provided on this form is correct to the best of my knowledge.
 Name (Capitals)


 Signed	(Accountant)	           	                                            Date	 D D         M M        2   0   0   Y


 Professional association


 Company name


 Company address




                                                                                             Company stamp




 D5 Applicant	and	Partner/Spouse	Declaration
 If you give false or incomplete information, or if you do not tell us about any part of your income that
       is relevant, you may be prosecuted.
 •	    I
       	 /We certify that the details of income and liability for tax given above are a true record of the figures
       which	will	be	submitted	to	H.M.	Revenue	&	Customs
 •	    I/We	understand	that	the	LSC	reserves	the	right	to	verify	these	figures	with	H.M.	Revenue	&	Customs	
       at any time, and I/we	authorise	H.M.	Revenue	&	Customs	to	disclose	this	information	to	the	LSC	for	this	
       purpose if requested to do so
 •	    I
       	f	H.M.	Revenue	&	Customs	changes	the	figures	on	this	form,	I/we will inform the ALG Assessment
       &	Payment	Body,	and	I/we understand that this may mean the assessment needs to be reviewed
 •	    I/We understand that if this results in a lower award being due, I/we understand that any future
       payments may be stopped and any payments received may need to be repaid.


        Each person whose income is shown on this form must sign the declaration below
                                or it will be returned to you.

Sign here                                Applicant                                   Partner/Spouse




Date	                          D D       M M       2   0   0   Y             D D        M M       2   0   0   Y




ALG 14

								
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