09/10/2018 Healthy Start » Online application form

Title: Mrs Date of birth: 02/03/1989

Surname: Waterfield National Insurance number: JR929656A
First Name: Sophia
Tick all the benefits you are getting:
Income Support Income related Employment and Support Allowance Income-based Jobseeker's Allowance
Child Tax Credit (with a family income of £16,190 or less per year) Working Tax Credit*
Universal Credit (with a family take home pay of £408 or less per month) None of these benefits

Line 1: 39 Main Street  

Line 2:  
Town: Swanland County: East Riding of Yorkshire
Postcode: HU14 3QP Telephone number: 07515008077

Title: Date of birth:

Surname: National Insurance number:
First Name:
Relationship to applicant:  
Tick all the benefits you are getting: 
Income Support Income related Employment and Support Allowance Income-based Jobseeker's Allowance
Child Tax Credit (with a family income of £16,190 or less per year) Working Tax Credit*
Universal Credit (with a family take home pay of £408 or less per month) None of these benefits

Title: Date of birth:

Surname: National Insurance number:
First Name:
Relationship to applicant:  

Title: Date of birth:

Surname: National Insurance number:
First Name:
Relationship to applicant:  
Tick all the benefits that your carer and your carer’s partner are getting (even if you are applying because you are pregnant
and under 18, as it will help us see if you may be able to get vouchers after your baby is born):

Income Support Income related Employment and Support Allowance Income-based Jobseeker's Allowance
Child Tax Credit (with a family income of £16,190 or less per year) Working Tax Credit*
Universal Credit (with a family take home pay of £408 or less per month) None of these benefits

I am included in my carer's/carer's partners claim for:

Income Support Income related Employment and Support Allowance Income-based Jobseeker's Allowance
Child Tax Credit (with a family income of £16,190 or less per year) Working Tax Credit*
Universal Credit (with a family take home pay of £408 or less per month) None of these benefits

*If you or your family receive Working Tax Credit, you do not qualify for Healthy Start unless pregnant and under 18. But do not tick
this box if your family is getting Working Tax Credit run-on only. See 'Do I qualify?'

https://www.healthystart.nhs.uk/healthy-start-vouchers/how-to-apply/online-application-form/? 1/2
09/10/2018 Healthy Start » Online application form

Name: Amyas Simpson-Young Date of birth: 26/08/2018

Name: Date of birth:
Name: Date of birth:

Are you pregnant?  Yes No

https://www.healthystart.nhs.uk/healthy-start-vouchers/how-to-apply/online-application-form/? 2/2