Relationship details - Separated under one roof form (SS293)

Use this form if you’re separated but live under the same roof as your ex-partner. This is so we can assess whether to pay you as a single person or as a member of a couple.

You and your ex-partner will each need to complete a form.

If it puts you at risk, they don’t need to complete this form.

Download and complete the Relationship details - Separated under one roof form.

You can fill and sign this form digitally in some browsers, or you can open it in Adobe Acrobat Reader. If you don’t have Adobe Acrobat Reader, you can print this form and sign it.

You can send the link of the form to your ex-partner. They need to return their completed form to you, so you can submit it with yours.

This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please use self service, request someone to deal with us on your behalf, or contact us. We can help you access, complete and submit them.

Page last updated: 9 July 2021