HMRC: Structured Email

*indicates required information

Before you complete this form please make sure you read the related guidance. This will help you to decide if a statement of your National Insurance account is the right product to meet your needs.

If you are requesting a statement of your National Insurance account please complete this form.

If you are an authorised agent, please complete the fields below with your client's information and enter your own details in the 'Agent's details' section.

Please note: For additional help you can click on the help icons (?) that appear next to various field labels below.

Please enter an email address in the field below. This will be used to send you responses about this form.

Email address:*

__________________________________________________

Your statement request

What is the first tax year you need on your statement? Please enter the year below.

6 April:*

What is the last tax year to be included on your statement? Please enter the year below.

5 April:*

Please note: HM Revenue & Customs (HMRC) will only include tax years that ended more than 12 months ago in your statement. This is because it can take quite some time for all of the National Insurance you have paid, or been credited with, to appear on your statement.

Please tick the appropriate checkboxes below, to tell HMRC why you want a statement of your National Insurance account.

Check for missing National Insurance contributions

I've used the wrong National Insurance number

Employer used the wrong National Insurance number

To confirm how many qualifying years I have

To pay Class 3 National Insurance

Other

If you have selected 'Other' please enter the reason in the box below.

Reason for requesting a statement:

__________________________________________________

Personal details

Please note: For security reasons and to help HMRC amend your details, you must answer all of the questions in this section.

If you do not have any middle names, please enter NONE in the appropriate field below.

Title (Mrs/Mr/Dr etc):

First name:*

Middle name(s):*

Last name:*

National Insurance number:*

Date of birth:*

dd/mm/yyyy

If you are currently resident in the UK please tick this box

I currently live in the UK

If you are currently resident outside the UK, please provide the date you left the UK.

Date left the UK:

dd/mm/yyyy

Address line 1:*

Address line 2:

Address line 3:

Country:*

Postcode (if abroad you may enter NONE):*

What date did you move to this address?

dd/mm/yyyy

Preferred daytime telephone number (inc STD):

Please tick the appropriate checkbox below.

This is my daytime business telephone number

This is my daytime home telephone number

This is my mobile telephone number

Previous name

If you were previously known by another name, please enter the details in the fields below. Please move to the next section if this does not apply to you.

Title (Mrs/Mr/Dr etc):

First name:

Middle name(s):

Last name:

Date of change of name:

dd/mm/yyyy

Reason for change of name:

Please tick the checkbox below if you are only 'known as' this name and it is not a legal change of name.

'Known as' for contact purposes only

Marriage or civil partnership

If you are married, separated or divorced, or in a civil partnership, please enter the details in the fields below. Please move to the next section if this does not apply to you.

Date of marriage or civil partnership:

dd/mm/yyyy

Date of separation:

dd/mm/yyyy

Date of divorce/dissolution of civil partnership:

dd/mm/yyyy

Spouse or civil partner's full name:

Spouse or civil partner's date of birth:

dd/mm/yyyy

If known, please enter your spouse or civil partner's National Insurance number or Unique Taxpayers Reference (UTR) below.

National Insurance number or UTR:

Previous address

If you previously lived at another address, please enter the details in the fields below. HMRC will use the previous address to confirm your identity if the address held does not match your present address, for example, if you have recently moved. Please move to the next section if this does not apply to you.

Address line 1:

Address line 2:

Address line 3:

Country:

Postcode (if abroad you may enter NONE):

Your current employer or pension provider

Please tick the checkbox below if you are not employed and are not in receipt of a private or occupational pension.

Not employed or receiving a pension.

Please enter the PAYE Reference of your employer or, if you are currently receiving private/occupational pension payments, your pension provider in the field below. (Please view the help text for further information on how to fill in this field and what to do if you don't have the required information). If you have more than one employer or private or occupational pension, please enter the details for the one you consider to be your main employer or pension provider.

Employer's or pension provider's PAYE Reference:*

Works number, or pension number (if applicable):

Name of current employer:

If you have changed jobs during the last two years, please enter the name of your previous employer in the field below.

Name of previous employer:

Works number, or pension number (if applicable):

Unique Taxpayer Reference:

If you are self-employed please tick the checkbox below to show how you pay your Class 2 National Insurance.

Direct Debit

Receive a bill twice a year

Have an exception so do not pay

If your only, or main, income is from a State Pension or benefit please tick the checkbox below to tell HMRC which type of benefit you are getting.

Retirement/State Pension

Bereavement benefits

Unemployment or low income benefits

Incapacity benefits for ill or disabled people

Benefit for caring for someone

If you ticked any of the checkboxes above, please tell HMRC the name of the benefit you are getting in the field below. For example Employment and Support Allowance, Widows benefit, Job Seekers Allowance.

Name of benefit:

__________________________________________________

Agent's details

If you are an authorised agent completing this form on behalf of your client, please enter your details in the fields below.

Agent's full name:

Agent's address line 1:

Agent's address line 2:

Agent's address line 3:

Country:

Postcode (if abroad you may enter NONE):

HMRC will include your client's reference in the response to you, but for data security reasons this will not include the client's name, National Insurance number or any other personal information.

Client reference:

__________________________________________________

After you click the 'Next' button you will see a preview page summarising the information you have provided. If this page is not displayed, please use the scroll bar to locate any missing or incorrect entries highlighted in red.

Request for statement of National Insurance account

__________________________________________________

Your statement request

__________________________________________________

Personal details

__________________________________________________

Agent's details

__________________________________________________