Social Welfare Services

Application form for CB 1

Data Classification R

Child Benefit
You need a Personal Public Service Number (PPS No.) for yourself and your
child(ren) before you apply.
How 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 black ball point pen.

• Please use BLOCK LETTERS and place an X in the relevant boxes.

• If you want to claim for any children aged 16 or 17 you should complete this
form and form CB2, which you can get online at www.welfare.ie, from your local
Social Welfare Office and from post offices.

You could lose out on benefit unless you complete and return this application
form within 12 months of the month in which:
- the child is born, or
- the child became a member of your family, or
- you and your family came to live in the Republic of Ireland, or
- you or your spouse, civil partner or cohabitant commence(s) employment here.
Note: Child Benefit is not paid for the month in which the child is born.

If you are applying later than 12 months after any of these events and you wish
to apply for arrears, you must give the reason(s) for the late application in Part 7
and attach written evidence.

• child benefit is normally paid to the mother or step-mother. In certain cases, it

can be paid to other people. The Department may need to get information from
other agencies about your application and may use details on this form to check
your eligibility for Child Benefit when contacting them.
applicant:
Fill in all Parts. When form is completed, sign declaration in Part 1.

If you need any help to complete this form, please contact your local Citizens
Information Centre, your local Intreo Centre, your local Social Welfare Office or
the Child Benefit Section.
Telephone:  (074) 916 4496
LoCall: 1890 400 400
If you are calling from outside the Republic of Ireland please call + 353 74 916 4496.
Note: The rates charged for the use of 1890 (LoCall) numbers may vary among
different service providers.
For more information, log on to www.welfare.ie.
 How to fill in first page of this form
To help us in processing your application:
• Print letters and numbers clearly.
• Use one box for each character (letter or number).
Please see example below.
1. Your PPS No.: 1 2 3 4 5 6 7 T
2. Title: (insert an ‘X’ or Mr. Mrs. X Ms. Other
specify)
3. Surname: M U R P H Y

4. First name(s): M A U R E E N
5. Your first name as it M A R Y
appears on your birth
certificate:
6. Birth surname: M C D E R M O T T
7. Your mother’s birth K E L L Y
surname:
8. Your date of birth: 2 8 0 2 1 9 7 0
D D M M Y Y Y Y

Contact Details
9. Your address: 1 N E W S T R E E T
O L D T O W N
D O N E G A L T O W N
County D O N E G A L Postcode

10.Your telephone number: O N E N U M B E R P E R B O X

MOBILE
O N E N U M B E R P E R B O X
LANDLINE
11.Your email address: O N E C H A R A C T E R P E R
B O X

SAMPLE
 Social Welfare Services

Application form for CB 1

Data Classification R

Child Benefit
Part 1 Your own details
1. Your PPS No.:
2. Title: (insert an ‘X’ or Mr. Mrs. Ms. Other
specify)
3. Surname:

4. First name(s):
5. Your first name as it
appears on your birth
certificate:
6. Birth surname:
7. Your mother’s birth
surname:
8. Your date of birth:
D D M M Y Y Y Y
Contact Details
9. Your address:

County Postcode

10.Your telephone number: MOBILE

LANDLINE

11.Your email address:

Declaration
I declare that the information given by me on this form is truthful and complete. I understand that if any
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 be prosecuted. I
undertake to immediately advise the Department of any change in my circumstances which may affect
my continued entitlement.
Date: 2 0
D D M M Y Y Y Y
Signature (not block letters)

Warning: If you make a false statement or withhold information, you may be

prosecuted leading to a fine, a prison term or both.
Part 1 continued Your own details
12.Are you? Single Cohabiting
Married In a Civil Partnership
Separated A surviving Civil Partner
Divorced A former Civil Partner
Widowed (you were in a Civil Partnership
that has since been dissolved)
13.If you are:
Married or entered into a civil partnership, from what date?

D D M M Y Y Y Y
Cohabiting, from what date?
D D M M Y Y Y Y
Separated, divorced or civil partnership dissolved, from what date?

D D M M Y Y Y Y
14.Are or were you getting Yes No
Child Benefit?
If ‘Yes’, please state:
Reference number:

Last date of payment:

D D M M Y Y Y Y
Country that pays you:
15.Do you have a Social Insurance Number or the equivalent, for example, National Insurance,
Pesel, CNP or ID Number?
Yes No
If ‘Yes’, please state:
Number:
16.Are you getting any other social welfare benefit or pension?
Yes No
If ‘Yes’, please state:
Country that pays you:
Name of benefit or
pension:
Reference number:
Part 2 Habitual Residence condition
17.Are you employed or self-employed?
Yes No
Please state:
If a Polish national, your
NIP number:
Name of country where
you work:
Name of country in which
you pay social insurance:
Name of employer:
Date you started your
current employment:
D D M M Y Y Y Y
If employed, please attach a letter from your employer, stating the date you started working,
your employer’s registered number and the class of social insurance paid.
18.If you have recently moved to the Republic of Ireland, when did you and your family move here?
You:
D D M M Y Y Y Y
Your spouse, civil partner
or cohabitant:
D D M M Y Y Y Y
Your children:
D D M M Y Y Y Y
19.What country were you
born in?
20.What is your nationality?
21.Have you lived in the Republic of Ireland continuously since the date you came to live here or
returned to live here?
Yes No
22.Please give details of each country outside the Republic of Ireland that you have lived in.
Country 1
Country:
Dates you lived there:
From:

To:
D D M M Y Y Y Y
Last address there:

Why did you live there?

Part 2 continued Habitual Residence condition
Country 2
Country:
Dates you lived there:
From:

To:
D D M M Y Y Y Y
Last address there:

Why did you live there?

Note: A separate sheet of paper can be used for more details if needed.
23.Have you lived at the same address for the last 2 years?
Yes No
If ‘No’, please give details of where you lived in the space provided.
Last address:

From:

To:
D D M M Y Y Y Y
Part 2 continued Habitual Residence condition
24.Does any of your or your spouse’s, civil partner’s or cohabitant’s close family, for example,
parent, brother or sister, live in the Republic of Ireland?
Yes No
If ‘Yes’, please state:
Person 1
Their surname:

Their first name(s):

Their date of birth:

D D M M Y Y Y Y
Their address:

Their relationship to you:

Date they came to the
Republic of Ireland:
D D M M Y Y Y Y
Person 2
Their surname:

Their first name(s):

Their date of birth:

D D M M Y Y Y Y
Their address:

Their relationship to you:

Date they came to the
Republic of Ireland:
D D M M Y Y Y Y
Part 2 continued Habitual Residence condition
Person 3
Their surname:

Their first name(s):

Their date of birth:

D D M M Y Y Y Y
Their address:

Their relationship to you:

Date they came to the
Republic of Ireland:
D D M M Y Y Y Y
Note: A separate sheet of paper can be used for more details if needed.
25.Do you have a current Garda National Immigration Bureau (GNIB) Card?
Yes No
If ‘Yes’, please state:
Your GNIB Number:
If ‘No’, please state:
Have you ever made an application for refugee status or leave to remain in the State?
Yes No
If ‘Yes’, please state:
Are you awaiting a decision on your application?
Yes No
If ‘Yes’, please provide verified copies of all relevant documentation from the Department of
Justice and Equality. Please do not post the original documents, as the Department of Justice
and Equality advise that you must keep the originals with you at all times.
Part 3 Your payment details
You can get your payment at a post office of your choice or direct to your current, deposit or
savings account in a financial institution. Please complete one option below.

Financial Institution
You will find the following details printed on statements from your
financial institution.
Name of financial institution:

Bank Identifier Code (BIC):

International Bank Account
Number (IBAN):

Name(s) of account holder(s):

Name 1:

Name 2 (if any):

Post Office
Please enter below the name and address of the post office where you wish to collect your
payment.
Post office name and address:

An Post childcare savings account

Account number:
You can get an application form for this account from your local post office.
Part 4 Details of your qualified child(ren)
26.Please give details here of child(ren) you wish to claim for.
Child 1
Their surname:

Their first name(s):

Are they: Male Female
Their date of birth:
D D M M Y Y Y Y
Their nationality:
How is the child related to
you?
Is this child living with you Yes No
in the Republic of Ireland?
If ‘No’, what country do
they live in?
Date they came to live with
you:
D D M M Y Y Y Y
Their Social Insurance Number or the equivalent, for example, National Insurance, Pesel, CNP or
ID Number:

Child 2
Their surname:

Their first name(s):

Are they: Male Female
Their date of birth:
D D M M Y Y Y Y
Their nationality:
How is the child related to
you?
Is this child living with you Yes No
in the Republic of Ireland?
If ‘No’, what country do
they live in?
Date they came to live with
you:
D D M M Y Y Y Y
Their Social Insurance Number or the equivalent, for example, National Insurance, Pesel, CNP or
ID Number:
Part 4 continued Details of your qualified child(ren)
Child 3
Their surname:

Their first name(s):

Are they: Male Female
Their date of birth:
D D M M Y Y Y Y
Their nationality:
How is the child related to
you?
Is this child living with you Yes No
in the Republic of Ireland?
If ‘No’, what country do
they live in?
Date they came to live with
you:
D D M M Y Y Y Y
Their Social Insurance Number or the equivalent, for example, National Insurance, Pesel, CNP or
ID Number:

Child 4
Their surname:

Their first name(s):

Are they: Male Female
Their date of birth:
D D M M Y Y Y Y
Their nationality:
How is the child related to
you?
Is this child living with you Yes No
in the Republic of Ireland?
If ‘No’, what country do
they live in?
Date they came to live with
you:
D D M M Y Y Y Y
Their Social Insurance Number or the equivalent, for example, National Insurance, Pesel, CNP or
ID Number:
Part 4 continued Details of your qualified child(ren)
27.How many children now under age 16 over age 16
live with you?
28.If any children are not living with you, please state name of the parent or guardian with
whom the child(ren) live:
Their surname:

Their first name(s):

Their birth surname:

Their date of birth:

D D M M Y Y Y Y
Their address:

Their relationship to the

child(ren):
Their Social Insurance Number or the equivalent, for example, National Insurance, Pesel, CNP or
ID Number:

If a Polish national, their

NIP number:
29.Are any of the children now living with you....?
Adopted: Yes No
Fostered: Yes No
Not your own: Yes No
If ‘Yes’, please state social worker’s:
Surname:

First name(s):

Address:

Telephone number: MOBILE

LANDLINE

Email address:
Part 4 continued Details of your qualified child(ren)
30.Do you have legal custody of your child(ren)?
Yes No

31.Do you support your child(ren)?

Yes No
For each child of school going age living in the Republic of Ireland, please attach a letter from
their school or college to confirm the date they started attending.
For each child not of school going age living in the Republic of Ireland, please attach a letter
from your doctor, the Gardaí, playschool or crèche to confirm that the child is normally living
in the Republic of Ireland.

Part 5 Your spouse’s, civil partner’s or cohabitant’s details

32.Their PPS No.:
33.Title: (insert an ‘X’ or Mr. Mrs. Ms. Other
specify)
34.Their surname:

35.Their first name(s):

36.Their birth surname:

37.Their Social Insurance Number or the equivalent, for example, National Insurance, Pesel,
CNP or ID Number:

38.If a Polish national, their

NIP number:
39.Their date of birth:
D D M M Y Y Y Y
40.Their address:
Answer this question only if
you do not live together.

41.Their nationality:
42.Are they getting Child Benefit?
Yes No
If ‘Yes’, please state:
Reference number:

Last date of payment:

D D M M Y Y Y Y
Country that pays them:
Part 5 continued Your spouse’s, civil partner’s or cohabitant’s details
43.Are they getting any other social welfare benefit or pension?
Yes No
If ‘Yes’, please state:
Country that pays them:
Name of benefit or
pension:
Reference number:
44.Are they employed or self-employed?
Yes No
Please state:
Name of country where
they work:
Name of country in which
they pay social insurance:
Name of their employer:
Date they started their
current employment:
D D M M Y Y Y Y
Part 6 Events that may affect your child benefit
You must notify Child Benefit Section in writing if any of these events occur.
• You change address
• You change post office
• You change bank or building society or An Post Childcare Account or account name
• A child aged 16 or 17 finishes education or changes or leaves school or college
• There is a death of a child for whom benefit is being paid
• You or your child are imprisoned or admitted to a home or detention centre
• A child is no longer living with you or in your care
• A child is abandoned, deserted or removed from your custody
• You or your child leave the State
• You marry or enter into a civil partnership or civil union
• You or your spouse, civil partner or cohabitant start(s) work in another EU country
• The person receiving child benefit dies
• You give birth to, adopt or foster further children
• Your family come to live in the Republic of Ireland

Part 7 late application details

If you have not applied within 12 months and you wish to apply for arrears, please give the
reason(s) why in the space provided:
Attach evidence in support of your reason(s) for claiming late if available.
Part 8 checklist
Have you enclosed the following?
Verified copy of certificate(s) of registration (GNIB card) for all non-EU and non-EEA
nationals*
Letter from school or college for each child of school going age living in the Republic of
Ireland confirming the date your child started attending
Letter from your doctor, the Gardaí, playschool or crèche confirming residency of each child
not of school going age living in the Republic of Ireland
Letter from your and your spouse's, civil partner’s or cohabitant’s employer with employer’s
registered number, the class of social insurance paid and start date of employment
Completed and signed HRC1 form for unemployed EU and EEA nationals and all non-EU and
non-EEA nationals
Completed CB2 form for children aged 16 or 17
Relevant documents from the Department of Justice and Equality if you have applied for
refugee or residency status
If your child(ren) were born outside the Republic of Ireland:
Original or verified copies of birth certificates, which must include the parent(s) name(s),
for each child you wish to claim for.*
Translations of birth certificates on their own are not sufficient.
* To have verified, please bring to any office of the Department of Social Protection.
Please note that only verified copies of the original versions of certificates are acceptable.

To avoid delay, please send all the certificates and documents that are needed with this form.
If you are sending in certificates or documents later, give details here:

Important: If you are sending in certificates or documents later, remember to include your full name,
present address and your PPS number with them.

If you have moved here from another country, please

remember to provide us with your last address in that
country at Question 22.
Please remember to sign the Declaration in Part 1.
If you have any difficulty in filling in this form, please contact your local Citizens Information
Centre, your local Intreo Centre or your local Social Welfare Office.
 Department use only

HRC satisfied HRC not satisfied HRC1 issued

I award payment of Child Benefit to the children named in Part 4.
I disallow payment of Child Benefit to the children named in Part 4.
With effect from: 2 0
M M Y Y Y Y
Date: 2 0
D D M M Y Y Y Y
Deciding officers signature (not block letters)

Send this completed application form to:

Child Benefit Section

Social Welfare Services
Department of Social Protection
St. Oliver Plunkett Road
Letterkenny
Co. Donegal
Telephone: (074) 916 4496
LoCall: 1890 400 400
If you are calling from outside the Republic of Ireland please call + 353 74 916 4496

Note: The rates charged for the use of 1890 (LoCall) numbers may vary among different service providers.

Data Protection Statement

Personal data is required to determine eligibility for payments and services, administered for
Ireland’s social protection system. It may be shared with other Government Departments/
Agencies where provided for by law. Data protection policy available at
www.welfare.ie/dataprotection or hard copy.
Explanations and terms used in this form are intended as a guide only and are not a legal interpretation.
0K 05-18 Edition: May 2018