Employer Certificate Social Welfare Services for …

1 Employer Certificatefor Paternity BenefitIf you are employed, your Employer must complete this form to certify you are entitled topaternity leave for the dates provided. PB 2 Social Welfare Services Data Classification RPPSN of employee:Name of employee:Expected due date ofbaby:D DMMY Y Y YPaternity LeaveStart Date:Paternity LeaveEnd Date: Employer s Payment Method DetailsThis section should only be completed if your employee has authorised that Paternity Benefit paymentswill be made directly to DMMY Y Y YFrom:D DMMY Y Y YTo:orFinancial InstitutionName of financial institution:Bank Identifier Code (BIC):International Bank AccountNumber (IBAN):Account Name(s):You will find the following details printed on statements from your financial s date ofbirth:D DMMY Y Y YPage 1 Note: If an employee is applying for paternity leave before their baby is born, they should supply theexpected due date of their baby.

2 Otherwise, the baby s date of birth can be provided. F3C7F17D8A6377A0 Employer s Contact DetailsName:Address: Employer s telephonenumber: Employer s email address:CountyPostcodeM O B I L EL A N D L I N EI/We certify that the employee is entitled to the period of paternity leave stated (notblock letters) Employer s official stampPosition in company or organisationYour name (INBLOCK LETTERS) Employer DeclarationWarning: If you make a false statement or withhold information, you may be prosecuted leadingto a fine, a prison term or you make any alterations after you complete the form, you must initial and datethem otherwise the information supplied cannot be s Registerednumber:Date of Certification:20D DMMY Y Y YPage 2B5400083992C3479 Page 30K 05-18 Edition: May 2018 Data Protection StatementPersonal data is required to determine eligibility for payments and Services , administered forIreland s Social protection system.

3 It may be shared with other Government Departments/Agencies where provided for by law. Data protection policy available or hard copy.