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To all 28<br />

Refer Informant to Prompt tid N<br />

PME BX<br />

52 Are you at present receiving any of the<br />

$ state benefits<br />

/<br />

shown on Card N?<br />

m,@~@<br />

.............. .............. .............. .............. .............. .............<br />

I s pl s pl E<br />

\<br />

Yes ,_.<br />

No to all _<br />

Exclude Income Snpport/Snpplemcntary ,<br />

benefit from (a) - (d)<br />

~ Exclude Christmas Bonus from (a) - (d) I<br />

(a) War disability pension<br />

and related<br />

allowance<br />

State<br />

(i) What was the amount of benefit<br />

you last received? ___<br />

(ii) How long did<br />

this cover? Enter<br />

period .—~<br />

code<br />

MOBIU~ (qq3R) ~osz~<br />

(b) Mobility allowance<br />

MOBU7MT @$ Q052B I<br />

Yes _c<br />

No —><br />

(i) What was the amount of benefit<br />

you last received?<br />

b (ii) How long did<br />

this cover? Enter<br />

period —__<br />

*<br />

code<br />

SEVbJSIi4 (4~5$ Q052C<br />

(c) Severe disablement<br />

allowance<br />

SEVbt@lT (+q5B~ Q052C t<br />

No z,<br />

1 1 1<br />

2 2 2 -Goto53<br />

PERckf12 (4-q3) QOS211 z If ~c 99<br />

specify period<br />

............................. ............................. ............................<br />

- Ask (i) & (ii)<br />

2 2 2 - Go to (c)<br />

............................. ............................<br />

If code 9,<br />

g (~~<br />

- Ask (i) & (ii)<br />

2 2 2 - Go to (d)<br />

(i) What was the amount of benefit<br />

(ii)<br />

you last received?.—<br />

How long did<br />

:B&@<br />

this cover? Enter<br />

period _ ............................. ............................ ............................<br />

If code 9,<br />

-~Nc (4~8~~ QOS~cOde<br />

(d) Attendance allowance<br />

- Ask (i) & (ii)<br />

No _ 2 2 2 -Goto53<br />

r m 9 !<br />

fmENbfwI (+wiiGio52b \<br />

(i) What was the amount of bd \<br />

you last received? -~<br />

.................. - ........ ~ .................. -,- ... .... .................. + ........ - Ask (ii)<br />

(ii) How “ long did<br />

this cover? Enter<br />

period _<br />

code<br />

p=c44q (*) Qo5m 2<br />

............................. ............................. ............................<br />

If COdC9,<br />

SpCCify ~~iod<br />

\<br />

.............................!............................. .............................

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