DPA - Benefits - DPA 678 - RHCEP Claim Form

The RHCEP Claim Form is available (see link below) in Adobe Acrobat 4.0 Portable Document Format (PDF). In order to use this form you must have Adobe Acrobat Reader 4.0 or higher installed on your computer. A Free copy of the Adobe Acrobat reader can be downloaded from the Adobe website.

This form must be printed out and then filled in.

Please read the following before attempting to use this form.

This form cannot be saved as an individual file.
This form cannot be filled in and submitted electronically.
DPA 678 - RHCEP Claim Form

Please remember to make a copy of the RHCEP Claim Form for your records.