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Get UK HMRC CA3916 2012

Your employer gives you this form when you stop working for them. When you have answered the questions and got the photocopies you need send them to us at the above address. We may not be able to send you an accurate statement without this information. Your statement may be delayed if we have to confirm your employment details with your previous employer s. CA3916 Page 1 HMRC 10/12 1 About you 3 Your time in the UK Title Put Mr Mrs Miss Ms or other title What date did you first arrive in the UK to live DD MM YYYY Surname or family name What was the last date you left the UK to live in an EEA country DD MM YYYY First names Did you live in the UK continuously between these dates Answer Yes if you were abroad for short periods for example for a holiday Any other surname or family name that you have used Yes If No please give the dates you were in the UK below From DD MM YYYY Gender put X in one box Male Female Your date of birth DD MM YYYY Nationality Daytime phone number including dialling code Are you a national of a European Economic Area EEA country Put X in one box No If you need more space please use the More information box on page 4. CA3916 Page 1 HMRC 10/12 1 About you 3 Your time in the UK Title Put Mr Mrs Miss Ms or other title What date did you first arrive in the UK to live DD MM YYYY Surname or family name What was the last date you left the UK to live in an EEA country DD MM YYYY First names Did you live in the UK continuously between these dates Answer Yes if you were abroad for short periods for example for a holiday Any other surname or family name that you have used Yes If No please give the dates you were in the UK below From DD MM YYYY Gender put X in one box Male Female Your date of birth DD MM YYYY Nationality Daytime phone number including dialling code Are you a national of a European Economic Area EEA country Put X in one box No If you need more space please use the More information box on page 4. 2 Where you live 4 Your last UK employer Country of residence after leaving the UK Employer s name and address Address in that country Your employer s tax district and PAYE reference number You can find these on your payslip form P45 or P60 that your employer gave you when you stopped working for them / Page 2 Enter the Jobcentre Plus phone number if you know it Continued Are you applying for a statement of National Insurance contributions to claim unemployment benefit abroad Start date of your Jobseeker s Allowance claim DD MM YYYY If No go to part 5 Your UK employers If Yes answer the following questions 5 Your UK employers Type of employment For example catering agriculture health care Please give us details of any other UK employment that you have had in the last three years. Information we need to send a statement of National Insurance contributions Customer Operations National Insurance Contributions and Employer Office International Caseworker Benton Park View NEWCASTLE UPON TYNE NE98 1ZZ United Kingdom Phone 44 191 203 7010 from overseas or 0845 915 4811 from the UK Fax 44 191 225 9570 Your National Insurance number Date About this form If you have downloaded this form from our website you can use it to ask for the following Portable document U1 a statement of National Insurance contributions NICs to assist any unemployment related benefit claims. Please note Self-employed contributions cannot be used to claim unemployment benefit. Form E301 A statement of National Insurance contributions NICs to assist any unemployment related benefit claims. If you are not an European Economic Area EEA national. Please note Self-employed contributions cannot be used to claim unemployment benefit. 2 Where you live 4 Your last UK employer Country of residence after leaving the UK Employer s name and address Address in that country Your employer s tax district and PAYE reference number You can find these on your payslip form P45 or P60 that your employer gave you when you stopped working for them / Page 2 Enter the Jobcentre Plus phone number if you know it Continued Are you applying for a statement of National Insurance contributions to claim unemployment benefit abroad Start date of your Jobseeker s Allowance claim DD MM YYYY If No go to part 5 Your UK employers If Yes answer the following questions 5 Your UK employers Type of employment For example catering agriculture health care Please give us details of any other UK employment that you have had in the last three years. If you need more space please use the More information box on page 4. Your job title If you don t have a UK National Insurance number we will need these details from the date you arrived in the UK until the date you left. Date you started working for this employer DD MM YYYY Date you stopped working for this employer DD MM YYYY Did you get paid Weekly Monthly What was your average weekly or monthly pay Employer s tax district and PAYE reference number Number of hours worked during this period Number of days worked during this period Why did you leave this job Dismissal Resignation Expiry of contract Redundancy 6 Your UK self-employment Have you been self-employed in the UK Termination of contract by mutual consent Did you claim Jobseeker s Allowance between the date you left this job and the date you left the UK If Yes please give the dates you were self-employed in the UK below If Yes tell us the name and address of the Jobcentre Plus office that you claimed from Page 3 Please give the following details for each period you were employed in the UK from the date you arrived in the UK until the Your payslip from each employer will have these details Personnel or staff reference number Payroll number Use this space if you need to give more details to answer any of the questions or use a separate sheet of paper and attach it to this form. Please tell us which question it refers to. A full statement of National Insurance contributions for your reference only. Please note If you need a statement of National Insurance contributions to assist any sickness related benefit claim in an EEA member state please contact the foreign institution where you have made your claim. You should tell them to contact us to ask for form SED S041. To do this they should complete form SED S040 and send it to us at the address shown above. Please tick the appropriate box fill in this form and send it to us at the address shown above. Please note we cannot issue these documents unless you are living in an EEA country are leaving the UK within the next two weeks or have a final UK payslip. If we have sent you this form it is because we have been asked to send details of your National Insurance contributions to help with your recent benefit claim in another EEA member state. If you are not an European Economic Area EEA national. Please note Self-employed contributions cannot be used to claim unemployment benefit. A full statement of National Insurance contributions for your reference only. Please note If you need a statement of National Insurance contributions to assist any sickness related benefit claim in an EEA member state please contact the foreign institution where you have made your claim. You should tell them to contact us to ask for form SED S041. To do this they should complete form SED S040 and send it to us at the address shown above. Please tick the appropriate box fill in this form and send it to us at the address shown above. Please note Self-employed contributions cannot be used to claim unemployment benefit. Form E301 A statement of National Insurance contributions NICs to assist any unemployment related benefit claims. If you are not an European Economic Area EEA national. Please note Self-employed contributions cannot be used to claim unemployment benefit. A full statement of National Insurance contributions for your reference only. Please note If you need a statement of National Insurance contributions to assist any sickness related benefit claim in an EEA member state please contact the foreign institution where you have made your claim. You should tell them to contact us to ask for form SED S041. If you need more space please use the More information box on page 4. Your job title If you don t have a UK National Insurance number we will need these details from the date you arrived in the UK until the date you left. Date you started working for this employer DD MM YYYY Date you stopped working for this employer DD MM YYYY Did you get paid Weekly Monthly What was your average weekly or monthly pay Employer s tax district and PAYE reference number Number of hours worked during this period Number of days worked during this period Why did you leave this job Dismissal Resignation Expiry of contract Redundancy 6 Your UK self-employment Have you been self-employed in the UK Termination of contract by mutual consent Did you claim Jobseeker s Allowance between the date you left this job and the date you left the UK If Yes please give the dates you were self-employed in the UK below If Yes tell us the name and address of the Jobcentre Plus office that you claimed from Page 3 Please give the following details for each period you were employed in the UK from the date you arrived in the UK until the Your payslip from each employer will have these details Personnel or staff reference number Payroll number Use this space if you need to give more details to answer any of the questions or use a separate sheet of paper and attach it to this form. Please tell us which question it refers to. 9 Declaration I declare that the information I have given on this form is complete and correct to the best of my knowledge and belief I will tell HM Revenue Customs straightaway if my circumstances or plans change in a way that affects the answers I have given on this form. Your signature Date DD MM YYYY Page 4 10 Checklist Please use this checklist to make sure you have put everything in the envelope that we need to send you an accurate statement. .

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