Form NI 12A
Medical Report Certifying Multiple Births
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Clear Form
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. National Insurance Number
5. Date of Birth
6. Telephone Number
Home
Phone
Office/Work
Phone
Cell
Phone
7. Did pregnancy last at least 26 weeks?
Yes
No
8. How many children were delivered?
9. Did you complete and submit:
(a) NI 12 - Maternity Benefit Application
Yes
No
(b) NI 13 - Special Maternity Grant Application
Yes
No
10. 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