b'1And if youre pregnant, or havea child under four, youll also geta voucher for free vitamins. Vitamintablets for you; drops for yourbaby or child. Helping them togrow up strong and healthy.So what vouchersdo I get? If youre pregnant you get one voucher a week worth 3.10 For each baby under the age of one, you get two vouchers a week worth a total of 6.20 For each child aged over one and under four, your family gets one voucher a week worth 3.10SERVICES THAT CAN HELP YOU4 b Your carers partner (if over 18 years old and living with you) Title Surname Date of birthD D M M Y Y Y YFirst NameNational Insurance numberRelationship to applicantTick all the benefits you are getting: Income Support Income-related Employment and Support Allowance Income-based Jobseekers Allowance Pension CreditChild Tax Credit (with a family income of 16,190 or less per year) Universal credit (with a family take home pay of 408 or less per month4 c Complete if you are 18 or 19 years old, in full-time education and pregnant I am included in my carers/carers partners claim for:Income Support Income-related Employment and Support Allowance Income-based Jobseekers Allowance Pension CreditChild Tax Credit (with a family income of 16,190 or less per year) Universal credit (with a family take home pay of 408 or less per month5Your children: Please give details of any children (under 4) you already have (continue on another of paper if necessary) First NameDate of birthD D M M Y Y Y YSurname First NameDate of birthD D M M Y Y Y YSurname First NameDate of birthD D M M Y Y Y YSurname 6 Are you pregnant? Yes No Estimated date of deliveryD D M M Y Y Y Y7 Please read thisPlease read this If you are 16 or over, sign and date the form I declare that the information given on this form and in anyyourself. If you are under 16, ask a parent or carer to sign andsupporting documents provided is complete and accurate. date the form.I understand and accept that if I provide false or misleading information I may be withdrawn from the scheme and I may be By signing:liable to prosecution and / or civil proceedings. I understand that the information I have provided will be usedto assess my application for Healthy Start and to issue Healthy Start vouchers.SignatureWe will use this information to check your application and tosupport the effective and efficient delivery of the Healthy StartName scheme. The information on this form may be disclosed in confidence to other public bodies as appropriate for the purposes of checking entitlement and preventing orDateD D M M Y Y Y Ydetecting fraud.From the 6 April 2020, we do not need a health professional signatureYou can post the completed form to Freepost RRTR-SYAE-JKCRHealthy Start Issuing Unit, PO Box 1067, Warrington, WA55 1EG30'