Form

Your consent

By signing below, I confirm that:

1. The information I have provided is true and complete to the best of my knowledge.

2. I appoint Evanshaw Ltd as my authorised tax agent for my Home Responsibilities Protection (HRP) and National Insurance (NI) matters, and consent to them contacting HMRC and DWP to request my NI record and DWP pension information and, where appropriate after review, preparing and submitting any necessary HMRC/DWP forms and correspondence on my behalf.

3. I understand that, as part of checking whether I have a valid HRP-related claim, Evanshaw may need to request a detailed National Insurance Statement of Account from HMRC for specific tax years relevant to my case. I consent to Evanshaw preparing that National Insurance Statement of Account request in my name and sending it to HMRC on my behalf.

4. I understand that Evanshaw works on a No Win No Fee basis. I will only be charged if my claim results in backdated arrears that I actually receive. I understand that any State Pension arrears (and any linked Pension Credit arrears) arising from an HRP correction are paid by DWP directly to me and will not be paid to Evanshaw (or any agent). If I receive arrears, I agree to pay Evanshaw’s success fee within 7 days of receipt. I understand that the success fee is 30% of the arrears I actually receive, plus VAT at 20% on that fee (a total of 36%).

5. I confirm that I understand and consent to Evanshaw Ltd acting on my behalf, that I have the ability and capacity to make this decision, and that I have read and agree to the [Terms & Conditions] and [Draft Conditional Fee Agreement].

6. I have been given the opportunity to review the final completed (filled-in) versions of the main forms and documents I am signing today via https://evanshaw.co.uk/crm/view-draft/{userid}, and I understand that I have a 14-day cooling-off period from today to cancel this agreement without paying any fee.
I understand that the CF411 claim form is not signed at this stage. If, after Evanshaw has reviewed my case and the supporting evidence, it is appropriate to submit a CF411 HRP claim to HMRC, Evanshaw will prepare the CF411 and ask me to sign it before submission.
I consent to signing electronically and understand that my electronic signature will have the same legal effect as a handwritten signature.

Tick to confirm all of the above

CRM ID

Full Name*

Email Address*

Telephone Number

Source Ref

OR

I cannot sign documents electronically and would prefer to receive a paper pack by post to sign with a pen.

Marital Status

Previous Name

When you were receiving Child Benefit for the children, what was the other parent’s full name (if known)?

Partner's Date of Birth (if known)?

Home Address (Postcode)

What was your previous address?

Mobile Telephone Number

National Insurance Number

Which year did you start receiving Child Benefit (Family Allowance)?

Which year did you stop receiving Child Benefit (Family Allowance)?

Between 1978 and 2000, how many children were you claiming Child Benefits (Family allowance) for?

Full Name (Child 1)

Date of birth (Child 1)

Full Name (Child 2)

Date of birth (Child 2)

Full Name (Child 3)

Date of birth (Child 3)

Full Name (Child 4)

Date of birth (Child 4)

Full Name (Child 5)

Date of birth (Child 5)

Was Child Benefit ever claimed or paid to anyone else for any of these children during 1978–2010 (for example, the other parent)?

Who claimed Child Benefit for the children?

What was their relationship to the children?

During the years you were caring for a child, were you working at any point?

Which years were you working? (Select all that apply)

Did you live outside the UK at any time between April 1978 and April 2010?

Please share the approximate dates

Have you ever paid voluntary National Insurance contributions to make up for any missing years?

Which years did you pay voluntary National Insurance contributions for?

Which year did you start receiving State Pension?

How much State Pension do you currently receive every 4 weeks?

Are you receiving Pension Credit?

Do all your children have the same father?

Father Name

Father DOB

Father 1 Name

Father 1 DOB

Father 2 Name

Father 2 DOB

Father 3 Name

Father 3 DOB

Father 4 Name

Father 4 DOB

Father 5 Name

Father 5 DOB

Father 6 Name

Father 6 DOB

Father 7 Name

Father 7 DOB