CLAIM FORM FOR SUPPLEMENTARY WELFARE ALLOWANCE (S.W.A.

1 - 07/2009)
PLEASE
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Office Use Date Received By Whom

Use BLOCK LETTERS. Answer all questions fully, as incomplete information may delay processing your claim. Read and sign the Declaration. Take the completed form together with evidence of Income/Outgoings to your local Community Welfare Officer. Supply a full length Birth Certificate for each person who does not already have a P.P.S. No.

PART 1 SURNAME FIRST NAME ADDRESS

APPLICANTS DETAILS P.P.S. NO. DATE OF BIRTH NATIONALITY TELEPHONE NO.

Do you have a Social Security Number from another country? If YES PLEASE STATE: State your Birth Surname: NUMBER COUNTRY Country of Birth:

YES

NO

Are you (PLEASE TICK (4) as appropriate): Single Married Separated

Male Widowed

Female Cohabiting Divorced

In Full-time Education YES NO

In Full-time Work YES NO

Involved in an Industrial Dispute YES NO

PART 2 FULL NAME ADDRESS

YOUR SPOUSE/PARTNERS DETAILS P.P.S. NO. DATE OF BIRTH NATIONALITY

Does he/she have a Social Security Number from another country? If YES PLEASE STATE: State his/her Birth Surname: Country of Birth: Is he/she (PLEASE TICK (4) as appropriate): In Full-time Work YES NO NUMBER COUNTRY

YES

NO

Involved in an Industrial Dispute YES NO

PART 3

CHILD DEPENDANT DETAILS

Please give details of children under 18 years of age who are dependent on you. Childs Name First Name Surname Date of Birth P.P.S. No. Relationship to you Does the child live with you YES/NO

PART 4

OTHER RESIDENTS

Apart from yourself, your spouse/partner and child dependants listed in Part 3, state who else lives with you?

First Name

Surname

Date of Birth

Relationship to you

Gross Income per week

PART 5

OCCUPATION, EMPLOYMENT AND GENERAL INFORMATION

PLEASE INDICATE:

(a)

All addresses resided at during the last 2 years. (If more than 1 previous address please provide other address(es) on a separate piece of paper)

(b)

Usual occupation. When last employed. Name & address of most recent employer.

(c)

PART 6

INCOMES AWAITED

Are you or your spouse/partner awaiting income from: Source A Social Welfare Claim Employment/Redundancy Payments A Social Security Claim to another State A Maintenance Order/Application A Pension Application A Compensation Claim Any Other Source PART 7 A. DETAILS OF MEANS Yourself Spouse/Partner YES NO YES NO Details

How much income weekly do you and your spouse/partner have from the following sources? Source Yourself Spouse/Partner Details

Social Welfare Payments Health Service Executive Payments Social Security Payments from another State Wages/Salary Self Employment (including farming) Sick Pay/Income Protection Schemes Occupational Pension(s) Maintenance Payments FAS Training Allowance Strike Pay Any other source(s) - PLEASE SPECIFY

B.

Have you or your spouse/partner investments in stocks, shares, or deposits with Banks/Building Societies or other Financial Institutions? YES If yes please provide details of: Amount(s) invested NO

Where invested

C.

Do you or your spouse/partner own any property (including land) other than the house you occupy? YES NO

If yes, please give the location and use of the property

PART 8 EMPLOYMENT/EDUCATIONAL SCHEMES How much are you or your spouse/partner in receipt of weekly from the following Schemes? Area Based Initiative / Back to Work Allowance Revenue Job Assist / Back to Education Allowance Community Employment Scheme / Other Scheme When did the payment(s) commence? (Date) PART 9 WEEKLY OUTGOINGS How much are you/spouse/partner paying weekly on: House Rent / Mortgage Maintenance Payments to another person Loans (Banks, Credit Union etc.) Travel Costs to Work

Yourself

Spouse/Partner

Yourself

Spouse/Partner

PART 10 OTHER INFORMATION Please indicate why you are applying for a Supplementary Welfare Allowance and give any additional information which you feel may be important in support of this application: -

PART 11

DECLARATION

I declare, that the information given by me in this application is correct and complete. I am aware that the making of any false or misleading statement or the concealment of any relevant information, or failure to disclose relevant information, are offences punishable by law. I undertake to advise the Health Service Executive immediately of any changes in circumstances including changes in income(s), dependency, address and/or any such changes relating to my spouse/partner which may occur affecting my eligibility for Supplementary Welfare Allowance. I understand and I am aware that I have a legal obligation to inform the Health Service Executive, immediately, of any changes in my circumstances affecting my right to Supplementary Welfare Allowance. I authorise the Health Service Executive to make all enquiries necessary to establish my current eligibility status and/or that of my spouse/partner and to make such enquiries as may be necessary on an on-going basis for review purposes. I also authorise that the requested information be provided to the Health Service Executive. I understand that if I am dissatisfied with a decision on my claim, I have a RIGHT OF APPEAL. I AM AWARE OF THE CONTENT OF THIS APPLICATION AND KNOWINGLY MAKE THIS DECLARATION

SIGNATURE OF APPLICANT SIGNATURE OF WITNESS

DATE DATE

If the applicant is unable to sign, his/her mark should be made and witnessed. The Witness should sign below.

IT IS AN OFFENCE TO GIVE FALSE OR MISLEADING INFORMATION. INFORMATION MAY BE SHARED WITH OTHER BODIES IN ACCORDANCE WITH LAW.