Form NI 12
Maternity Benefit Application
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Section A - To be completed by applicant
1. Name
First Name
Middle Names (if any)
Surname
2. Home Address
Street Address
City / District / County
3. Postal Address
My Postal Address is DIFFERENT from my Home Address
4. Valid Identification Document
Electoral Identification Card
Passport
Driver's Permit
5. National Insurance Number
6. Date of Birth
7. Email Address
8. Was Evidence of Date of Birth Previously Submitted?
Yes
No
9. Telephone Numbers
Home
Phone
Office/Work
Phone
Mobile
Phone
10. Have You Changed Your Name of Marital Status Since Registration?
Yes
No
11. Occupation
12. Business Name of Employer
13. Employer's Address
Street Address
City / District / County
14. Name of Actual Place of Work
(e.g. School/Department/Division)
15. Address of Actual Place of Work
Street Address
City / District / County
16. Are You Currently Employed Elsewhere?
Yes
No
17. Last Date Worked
Period of Absence
Start Date
End Date
18. Please indicate the method of payment of benefit
Mail to my Postal Address
Deposit to Financial Institution
Particulars of Witness to Mark (Where Claimant cannot sign)
Is the Claimant able to sign?
Yes
No
Witness Name
First Name
Middle Names (if any)
Surname
Address
Street Address
City / District / County
Occupation
Identification
Electoral Identification Card
Passport
Driver's Permit
Submit and Print