Transcription of Social Welfare Services Application form for AGENT ...
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Social Welfare Services Application form for AGENT ...
Page 1 Part 1 Customer details1. PPS Number: 2. Surname:3. First names: Application form forAuthority to Appoint an AGENT (other than HSE)5. Address: Please use BLACK ballpoint pen. Please use BLOCK LETTERS. Please answer all questions that apply to Telephone number:7. Email address: 8. Name of Social Welfare allowance or pension in payment: 4. Date of birth: D D M M Y Y Y Y9. If resident in a nursing home, hospital or care centre, please state:Name of nursing home, hospital or care centre:Address of nursing home, hospital or care centre:Telephone number of nursing home, hospital or care centre: D D M M Y Y Y YDate of admission:L A N D L I N EData Classification RSocial Welfare Services AGENTC ountyEircode or PostcodeCountyEircode or PostcodePage 2 Customer details Part 1 continuedYou should not feel obliged or be put under pressure to appoint an AGENT to collect your payment.
Where a person is unable to manage their own financial affairs, and the agent is appointed by the . Minister, the agent is responsible for ensuring that: • he or she acts in a personal capacity and does not delegate responsibility to any other person; • the payment is used for the benefit and best interests of the customer;
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