OPEN - ESDS

To all
29
PFNE B2q
Per No. Per No. Per No.
Refer informant to Prompt Card O
53 In the last t2 months. that is
since ................... have you received
any of the state benefits shown
I
* ...................................................................................I
11111
!
I
p:~ p:s P;chde
on Card O?
13EUcnRb@ (500$ Q05
No to all _
1 1
m
1 [
,, (a) Statutory Sick Pay
B from your employer?
.(i)
(ii)
For how many weeks did
you receive Statutory
Sick Pay?
Are you receiving Statutory
Sick Pay at present?
(b) N.I. sickness benefit
~~=111-.k.)
2; 2; 2; ‘=
:=-.,(.)
.................. ........ .................. ........ .................. ........
~~=ii::::~
I I I I
–DYmi-- .
(i) For how many weeks
did you receive this
benefit?
I I I
I
/.
4) (ii) What was the amount of
-.
benefit you last received? -~ (iii)
(iii)
(iv)
How long did this
cover?
Are you receiving
benefit at present? “
1 1 1 I
Enter
period —~
code -
............................ ............................
‘={
,“
............................. ............................. .............................
:,-ml-.,(.)