Application form for Social Welfare Services …

You need a Personal Public Service Number (PPS No.) before you you have qualified children and don t qualify for a Widow s, Widower s or Surviving Civil Partner s Contributory Pension you should apply for a One-Parent Family Payment to complete this Application form . Please use this page as a guide to filling in this form . Please answer all questions. Incomplete forms will be returned and this may delay your Application . Please use blaCkball point pen. Please use BLOCK LETTERS and place an X in the relevant in all Parts as they apply to you. When form is completed, read Part 9and sign declaration in Part you need any help to complete this form , please contact your local Citizens Information Centre, your local Intreo Centre or your local Social Welfare more information, log on to :If you do not claim within3 monthsof becoming eligible, you could lose some 1 Social Welfare Services Data Classification RApplication form forWidow s, Widower s or Surviving Civil Partner s (Non-Contributory) PensionImportantIf you fail to provide relevant information or if you provide information which is untrue or misleading you will be required to repay any payment you received from the Department and you m

Part 1 Your own details WP 1 Social Welfare Services Data Classification R Signature (notblock letters) Date: D D MM Y Y Y Y 20 Declaration 10.Your telephone number:

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