Application form for Social Welfare Services …

1 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 may be prosecuted.

2 You must notify the Department of any change in your to fill this formTo help us in processing your Application : Print letters and numbers clearly. Use one box for each character (letter or number).Please see example HYMAUREENMCDERMOTTL A N D L I N EM O B I L E28021970O NECHARACTE RPERBOX1. Your PPS No.: 3. Surname:7. Your date of birth: 4. First name(s):D D MMY Y Y Title: (insert an X orspecify)6. Birth surname:5. Your first name(s) asappear(s) on your birthcertificate: telephone email address:Contact DetailsXMARY8. Your mother s birthsurname:KELLYO NENUMBERP ERBOXO NENUMBERP ERBOX1 NEWSTREETOLDTOWNDONEGALTOWN9. Your address: CountyPostcodePart 1 Your own detailsWP 1 Social Welfare Services Data Classification RSignature(notblock letters)Date:D D MMY Y Y telephone email address:Contact DetailsM O B I L EL A N D L I N EWarning: If you make a false statement or withhold information, you may beprosecuted leading to a fine, a prison term or declare that the information given by me on this form is truthful and complete.

3 I understand that if any of theinformation I provide is untrue or misleading or if I fail to disclose any relevant information, that I will be requiredto repay any payment I receive from the Department and that I may be prosecuted. I undertake to immediatelyadvise the Department of any change in my circumstances which may affect my continued Your PPS No.: 3. Surname:7. Your date of birth: 4. First name(s) Title: (insert an X orspecify)6. Birth surname:D D MMY Y Y YSignature of witness (notblock letters)Date:D D MMY Y Y Y20If you cannot sign your name, make a mark, such as an X and have it Your address: 5. Your first name(s) as appear(s)on your birth certificate: Application form forWidow s, Widower s or Surviving Civil Partner s(Non-Contributory) Pension8. Your mother s birth surname:CountyPostcodeIf Yes , please give details of all employments in Ireland, starting with your firstemployer:Employer s name:Employer s address:Dates youworked there:Job title:From:To:D D MMY Y Y YEmployer 1 Employer s name:Employer s address:Dates youworked there:Job title:From:To:D D MMY Y Y YEmployer 2 Note: A separate sheet of paper can be used for more details if date did yourspouse or civil partnerdie?

4 Date did you getmarried or enter into acivil partnership?D D MMY Y Y YD D MMY Y Y YPart 1 continuedYour own detailsYour work and claim details Part 2 Widow s, Widower s or Surviving Civil Partner s Non-Contributory is a means tested are legally obliged to declare all your means which include money in cash or in a financialinstitution, savings, shares, bonds, funds, property (other than your own home), foreign pensionsetc. Please include written evidence such as statements and payslips with your (a). Have you ever been employed in Ireland?YesNoYour work and claim details Part 2 continued Employer s name:Employer s address:Gross weekly earnings:Please attach 3 of your most recent payslips. 14(b). Are you employed atpresent?YesNoIf Yes , please state:a week ,.15(a). Were you ever self-employed in the Republic of Ireland?

5 Dates of self-employment:From:To:D D MMY Y Y YYesNoIf Yes , please state:15(b). Are you self-employed at present?Type of work you do:Net yearly earnings:a yearD D MMY Y Y YDate you started self-employment: .,This is the money you have made from self-employment after deducting operating Yes , please state:Type of payment claimed: Your address at that time:Your claim or you ever claimed a payment from this Department before?YesNoIf Yes , please you like us to consider you for a Widow s,Widower s or Surviving Civil Partner sContributory Pension?Part 2 continuedYour work and claim details you getting a Social security payment from another country?Name of country:Your claim or referencenumber:Amount:Please attach the most recentpayslip or letter from the Social Security Agency confirming the aboveamount and also provide a 3 month bank statement for the account to which this payment is Yes , please state:a week.

6 You getting any other pension or allowance?Who pays this pension:Your claim or referencenumber:Amount:Please attach the most recentpayslip or letter from the people who pay you confirming the aboveamount and also provide a 3 month bank statement for the account to which this payment is Yes , please state:a week ,. you ever lived or worked outside the Republic of Ireland?Note: A separate sheet of paper can be used for more details if :Employer s name: Your Social insurancenumber while there:Type of work:Your address whileliving/working there:Dates youworked there:From:To:D D MMY Y Y YYesNoIf Yes , please give details below. We will notify other countries covered by EU Regulations orBilateral Agreements that you may be entitled to a pension from work and claim details Part 2 continued you own, share in the ownership, work or rent a farm or land?

7 Size of farm or land:acresNet yearly income orrent from farm or land: ., Net yearly income is money you have made from the farm afterdeducting operating expenses. YesNoIf Yes , please you own stocks, shares (including shares in a creamery or Co-op), annuities, bonds, funds,insurance policies or investments?Their value:Please attach a statement to show details and current market value. YesNoIf Yes , please state: ., you have savings or accounts in a bank, post office, building society, credit union or anyother financial institution in the Republic of Ireland or another country?YesNoName of financial institution:Current balance:Financial Institution 1If Yes , please state: .,International BankAccount Number (IBAN):Name(s) of account holder(s):Name 1:Name 2 (if any):Is this account a joint account?YesNoBank Identifier Code (BIC):Please attach an original statement for each account, showing transactions for the last 3 you have any other accounts you must give details of them to this Department on aseparate sheet of of financial institution:Current balance:Financial Institution 2.

8 ,International BankAccount Number (IBAN):Name(s) of account holder(s):Name 1:Name 2 (if any):Is this account a jointaccount?YesNoBank Identifier Code (BIC):Part 2 continuedYour work and claim details you have property apart from your home?Type of property:Address of property: Property would be anapartment, businessproperty, another house orland other than thatmentioned at question 21. ,.,Current market value:YesNoIf Yes , please state:a week ,.Rent from this property:Please provide a valuation from a registered auctioneer or you paying a mortgage, a housing loan, or rent for your home? How much do you pay:Please attach documentary evidence. YesNoIf Yes , please state:a week ,. you payingmaintenance?Amount:YesNoIf Yes , please state:a week ,.Please provide a copy of the maintenance work and claim details Part 2 continued ever sell or transferany property or business?

9 You have any otherincome?YesNoIf Yes , please give details in the space provided:YesNoIf Yes , please give details in the space provided and attach a copy of the deed of you moved fromyour home?YesNoIf Yes , please outline the circumstances in the space provided. If your home is rented,occupied by other people or otherwise being used, please give recently sell yourhome to buy another?YesNoIf Yes , please outline the circumstances in the space provided and attach supporting documentsregarding the financial transaction from your solicitor and a copy of the Deed of Transfer: you have not applied within 3 months of your late spouse s/civil partner s death, pleasegive a reason why in the space you receivingmaintenance?Amount:YesNoIf Yes , please state:a week ,.Please provide a copy of the maintenance 3 Habitual Residence legally entitled to reside in the Republic of Ireland?

10 D D MMY Y Y YALL qUESTIONS mUST BE you born outsidethe Republic of Ireland?YesNoIf Yes , please state:Country you were born in:Your nationality:You must provide your original Birth Certificate with your are not Yes , when did you come to live in the Republic of Ireland? YesNoIf you are a holder of a GNIB (Garda National Immigration Bureau) card, please provide a copyof this card and your letter from the Department of Justice and lived outside the Republic of Ireland for any period longer than three monthswithin the last five years? Your payment details Part 4 If you are unable to collect or cash your payment at the post office and you want someone else(known as an agent) to do so for you, please complete the form AGENT authority to appoint an agentavailable on payments Part 5 This allowance is subject to your household composition.