Are you (or is the person you live with) eligible for one of the following benefits (whether you actually claim it or not):

Personal independence payment (PIP) - the daily living component
Disability living allowance (DLA) - the middle or higher rate care component
Income-based jobseeker's allowance (JSA) - with a disability premium
Employment and support allowance (ESA)
Universal credit
Severe disablement allowance
Income support with a disability premium
Incapacity benefit
Attendance allowance
Constant attendance allowance
Armed forces independence payment
Unemployability supplement or unemployability allowance
Working tax credit - with a disability element and you previously received disabled person's tax credit, incapacity benefit, severe disablement allowance or income support with a disability premium

Yes No

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