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Qu9stJonnaarm Raf<br />

Quastxon No<br />

Q3(G)<br />

Q3(G) (i)<br />

Q3(H)<br />

Ceding Shmmt<br />

R9formnco<br />

Q3G<br />

Q3Gi mmunt<br />

Q3H<br />

Q3(H) (1) Q3H1 amount 5<br />

Q3(I) Q3 I 2<br />

No of<br />

Box9s/<br />

CJmractmrs<br />

2<br />

5<br />

3-s 2=p<br />

2<br />

3-f 2-p<br />

Codang Inltruct~ons/Ramark8<br />

va 1Ue, -3-01<br />

Prmaently rmc91vang<br />

Attendance Allowance<br />

Yin ......................01<br />

NB. Thxs X8 paid to disabled<br />

person, not to caror.<br />

~ues -- 1000Q<br />

Only applias if coded<br />

1 above.<br />

Entar amount.<br />

~lues -- Oa<br />

Presantly recoivmg widows<br />

allowanco ●tc (Widowed<br />

140thars Allowance, War<br />

Widows Pens~on) .<br />

Ye* . ........ ..... ........01<br />

Va 1Umm -3-10000<br />

Only appllma If codad<br />

1 above.<br />

Enter amount.<br />

Presantly receiving any<br />

other atata banef~t<br />

Q3(I) (1) Q31(1) 2 Values -3-14<br />

Yes. .. ............. ....01<br />

Type of benaf ~t.<br />

Mat9rn~ty allowancm. . . 01<br />

Induatrxal ln]ury bencf~t/<br />

~ndumtr~al death. ........02

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