Data Classification R Application form for self-employed ...

1 You need a Personal Public Service Number (PPS No.) before you to complete this Application : You musthave your business approved by your Local Integrated Company or a Case Officer from this Department before you start self-employment. If your Application is successful, you mustregister as self-employed with Revenue. Please use this page as a guide to filling in this form. Please use blaCkball point pen. Please use BLOCK LETTERS and place an X in the relevant boxes. Please answer all questions that apply to you. If a question does not apply to you, please leave the answer area you do not have a spouse, civil partner or cohabitant fill in Parts 1, 2, 3, 4and 5as they apply to you.

2 When form is completed, sign declaration in Part you have a spouse, civil partner or cohabitant fill in Parts 1, 2, 3, 4, 5and 6as they apply to you. When form is completed, sign declaration in Part you need any help to complete this form, please contact your local Citizens Information Centre, your local Intreo Centre, your local Social Welfare Office orLocal Integrated Development more information, log on to form for self-employed people under theBack to Work Enterprise AllowanceBTW 2 Social Welfare Services Data Classification RPlease NoteThe European Commission is providing co-funding to this scheme for participants under 25 years.

3 The scheme is being backed jointly by the Youth Employment Initiative (YEI), the European Social Fund (ESF) and the Department of Social Protection on an equal funding basis. You may be contacted by the Department or its agents for follow up questions as part of the 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 A N D L I N EM O B I L E28021970 ONECHARACTERPERBOX1. Your PPS No.:3. Surname:7. Your date of birth:4. First name(s):D DMMY Y Y : (insert an X orspecify)6.

4 Birth surname:5. Your first name(s) asappear(s) on your telephone email address:Contact DetailsXMARY8. Your mother s birthsurname:KELLYONENUMBERPERBOXONENUMB ERPERBOX1 NEWSTREETOLDTOWNDONEGALTOWN9. Your address:CountyDONEGALP ostcodePart 1 Your own detailsI declare that the information given by me on this form is truthful and complete. I understand that ifany of the information I provide is untrue or misleading or if I fail to disclose any relevant information,that I will be required to repay any payment I receive from the Department and that I may beprosecuted.

5 I undertake to immediately advise the Department of any change in my circumstanceswhich may affect my continued entitlement. If I cease being self employed or leave the country I willnotify the Department as soon as (notblock letters)Date:D DMMY Y Y Y20 Warning: If you make a false statement or withhold information, you may beprosecuted leading to a fine, a prison term or telephone email address:Contact DetailsM O B I L EL A N D L I N E1. Your PPS No.:3. Surname:7. Your date of birth:4. First name(s) : (insert an X orspecify)6. Birth surname:8.

6 Your mother s birth surname:D DMMY Y Y Y9. Your address:5. Your first name(s) as appear(s)on your birth certificate:CountyPostcodeBTW 2 Social Welfare ServicesData Classification RApplication form for self-employed people under theBack to Work Enterprise AllowanceYour own detailsPart type of social welfare payment are you getting? you are getting Jobseeker s Benefit or Jobseeker s allowance , please you taking or have you taken part in any of the following courses or schemes? You must give evidence that you have taken part in any of these courses or schemes whenyou send in your you received a Back to Work allowance or Back to Work Enterprise allowance before?

7 YesNoIf Yes , please give of payment:Amount:a week ,.D DMMY Y Y YWhen you last signed on:Type of course orschemeIf Yes (X)Date you started course or schemeDate you finished course or schemeD DMMY Y Y YD DMMY Y Y YFull-time Solas/F Straining courseCommunityEmploymentCommunityServic esProgramme T sRural SocialSchemeFastrack toInformationTechnology (FIT)Back toEducationAllowanceVocationalTrainingOp portunitiesScheme (VTOS)F ilte Irelandtraining courseSocial EconomyProgramme D DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YD DMMY Y Y YDetails of your qualified child(ren)Part many children doyou wish to claim for?

8 Underage 18age 18 - 22 in full-time eductionYou must attach written confirmationfrom the school or college for thechildren aged 18 - 22 Please state child s:Surname: PPS No.: First name(s):Surname: PPS No.: First name(s):Surname: PPS No.: First name(s):Your payment detailsPart 3 Financial InstitutionIf you qualify you can get your payment direct to your current, deposit or savingsaccount in a financial institution. Please complete your details of financial institution:Sort code:Account number:Bank Identifier Code (BIC):International Bank AccountNumber (IBAN):You will get the following details printed on statements from yourfinancial institution.

9 Name(s) of account holder(s):Name 1:Name 2 (if any):Details of self-employment projectPart does your business or project involve? you any relevant training or work experience? do you propose to start your business or project?If Yes , please givedetails of training orwork you intend to employ people in your business or project? you applied for or received any financial support from other sources for any part of thisbusiness or project?If Yes , please give details:If Yes , please state:(You may qualify for a grant for taking on new employees)YesNoD DMMY Y Y YYesNoYesNoName of agency ororganisation:Amount you got (if notreceived, amountapplied for):Purpose:Agency or organisation 1.

10 , you a detailed business plan for your business?YesNoDetails of self-employment projectPart 5 details of cost as you registered as self-employed with Revenue?Start-up costs:List your own resourcesinvested and any loans orgrants you have receivedor applied for:Back to Work Enterprise allowance ConditionsYou must tell us at the Department of Social Protection if: you, or any person for whom payment is included in your allowance , dies, leaves the country, takes up a F S course, becomes entitled to a social welfare payment or is detained in legal custody, you are no longer self-employed or you take up or organisation 2 Agency or organisation 3.