Form NI 13
Special Maternity Benefit Application
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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. Valid Indentification
Electoral Identification Card
Passport
Driver's Permit
7. Marital Status
-- select an option --
Single
Married
Divorced
Widowed
8. Telephone Number
Home
Phone
Work
Phone
Cell
Phone
9. Name of Father of Child
First Name
Middle Names (if any)
Surname
10. Please indicate the method of payment of benefit
Mail to my Postal Address
Deposit to Financial Institution
11. Are you currently employed?
Yes
No
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