Fillable Printable Application Form for Maternity Benefit
Fillable Printable Application Form for Maternity Benefit
Application Form for Maternity Benefit
How to complete this application form.
• Please use this page as a guide to filling in this form.
• Please use black ball point pen.
• Please use BLOCK LETTERS and place an X in the relevant boxes.
• Please answer all questions that apply to you.
• You need a Personal Public Service Number (PPS No.) before you apply.
Employee or Self-Employed:
If you are an employee or self-employed fill in Parts 1, 2, 3, 5, 7 and 8 as they
apply to you. When form is completed, read Part 9 and sign declaration in Part 1.
Please note photocopies of this declaration are not acceptable.
To qualify for the maximum period of 26 weeks maternity leave, an employee
must take at least 2 weeks before the end of the week in which her baby is due.
Doctor:
Please only complete and stamp Part 6 after the 24
th
week of pregnancy.
Employer:
Please only complete and stamp Part 4 after the 24
th
week of pregnancy.
It is acceptable to forecast your employee’s PRSI contributions for any period
after the 24
th
week of pregnancy up to the date she starts maternity leave.
If your employee has been working for you for less than 12 months before the
start of her maternity leave, please forward a copy of her P45 from her previous
employment.
If you need any help to complete this form, please contact Maternity Benefit
Section, your local Citizens Information Centre, your local Intreo Centre or your
local Social Welfare Office.
For more information, log on to www.welfare.ie.
Important:
Submit this form at least 6 weeks (12 weeks if self-employed) before you intend
to start maternity leave.
Please do not submit this form more than 16 weeks before the end of the week in
which your baby is due.
Application form for
Maternity Benefit
Data Classification R
Social Welfare Services
MB 10
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.
SAMPLE
Contact Details
1 2 3 4 5 6 7 T
M U R P H Y
M A U R
E E N
M C D E R M O T T
2 8 0 2 1 9 7 0
1. Your PPS No.:
3. Surname:
8. Your date of birth:
4. First name(s):
D D MM Y Y Y Y
Mr. Mrs. Ms.
Other
2.
Title: (insert an ‘X’ or
specify)
6. Birth surname:
5. Y
our first name as it
appears on your birth
certificate
:
X
M A R Y
7. Your mother’s birth
surname:
K E L L
Y
L A N D L I N E
M O B I L E
O N E C H A R A C T E R P E R
B O X
10.Y
our telephone number:
11.Your email address:
O N E N U M B E R P E R B O X
O N E N U M B E R P E R B O X
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
9. Your address:
County D O N E G A L Postcode
Application form for
Maternity Benefit
Part 1
Your own details
1. Your PPS No.:
3. Surname:
8. Your date of birth:
4. First name(s):
Mr. Mrs. Ms.
Other
2.
Title: (insert an ‘X’ or
specify)
6. Birth surname:
5. Y
our first name as it
appears on your birth
certificate
:
Original signature only (not block letters and no photocopies)
Date:
D D MM Y Y Y Y
2 0
9. Your address:
Declaration
7. Your mother’s birth
surname:
D D MM Y Y Y Y
Contact Details
Data Classification R
Social Welfare Services
MB 10
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.
I authorise the Department to disclose details of my Maternity Benefit claim to my employer.
10.Y
our telephone number:
11.Your email address:
M O B I L E
L A N D L I N E
The Department is required, by legislation, to share information with the Office of the Revenue Commissioners.
Warning: If you make a false statement or withhold information, you may be prosecuted leading
to a fine, a prison term or both.
County
Postcode
Part 1 continued Your own details
Your work and claim details Part 2
13.From what date are you married, in a civil partnership or cohabiting?
D D MM Y Y Y Y
15.Are you getting or have you applied for any social welfare payment(s)?
Name of payment:
Amount: a week
€
,
.
Name of payment:
Amount: a week
€
, .
12.Are you?
Single
Married
Separated
Divorced
Widowed
Cohabiting
In a Civil Partnership
A surviving Civil Partner
A former Civil Partner
(you were in a Civil Partnership
that has since been dissolved)
16.If you are getting a pension or allowance from another country, please state:
Name of country:
Your claim or reference
number:
Amount:
a week
€
,
.
14.Were you married in the Republic of Ireland?
Yes
No
If ‘No’, please submit a verified copy of your marriage certificate (See Part 9 Checklist for
details).
Yes
No
If ‘Yes’, please state:
Your work and claim details Part 2 continued
You are ‘employed’ when you work for another person or company and you get paid for this work. If
you are employed, please continue to complete the questions below. If you are currently self-employed
only, please go straight to question 24. If you are not employed, please go straight to question 23.
‘Gross pay’ is your pay before tax, PRSI, union dues or other deductions.
19.If you are currently employed, please state:
Employer’s name:
Employer’s address:
Gross weekly earnings: a week (approximately)
€
, .
Employer’s telephone
number:
Job title:
18.Are you currently
employed?
If ‘Yes’, please state:
Are you?
Employed only
Self-Employed only Both
Yes No
If ‘Yes’, please state:
D D MM Y Y Y Y
Dates you worked
there:
Type of work:
From:
To:
Note: A separate sheet of paper can be used for more details if needed.
17.Have you lived, been employed, or received a social welfare payment in another EU country
in the last 4 years?
Country:
Employer’s name:
Your social insurance
number while there:
Employer’s address:
M O B I L E
L A N D L I N E
Yes No
Part 2 continued Your work and claim details
21.If you started work for the first time within the last 3 years, when did you start?
22.Are you related to your
employer?
If you are an employee your employer(s) must complete Part 4.
How are you related to
them?
D D MM Y Y Y Y
Yes No
Your last employer’s
telephone number:
Job title:
23.If you are no longer in
employment, please state
the date you last worked:
D D MM Y Y Y Y
Your last employer’s name:
Their address:
Please enclose a copy of your P45 showing the date you last worked.
M O B I L E
L A N D L I N E
20.Do you currently have more than one employment?
Yes
No
Please note that if you have more than one employer, each employer must complete Part 4 (a
photocopy of Part 4 or a letter signed by your employer containing the same information will do).
Were you related to this
employer?
If ‘Yes’, how were you
related to them?
Yes
No
If ‘Yes’, please state:
Your work and claim details Part 2 continued
25.Please state your:
Your
business registration
number:
Business name:
Business address:
Your business telephone
number:
26.When do you intend to
start maternity leave?
D D MM Y Y Y Y
M O B I L E
L A N D L I N E
27.Date you intend to return
to self-employment after
your maternity leave?
D D MM Y Y Y Y
28.Is your company a limited
company?
If ‘Yes’, please attach a copy of your P35 for the relevant tax year (this is two years’ prior to
the year in which your maternity leave starts).
Yes
No
29.Are you a sole trader?
If ‘Yes’, please attach your self-assessment acknowledgement form you will have received
from the Revenue Commissioners and accompanying Form 11 for the relevant tax year (this
is two years’ prior to the year in which your maternity leave starts).
Yes
No
Remember to send in the relevant certificates and documents with this application.
24.Are you or have you ever
been self-employed?
Your occupation:
Date you started self-
employment:
If you recently started self-employment, please send confirmation of registration from Revenue.
If you are no longer self-
employed, when were you
last self-employed?
Yes
No
If ‘No’, please go to Part 3.
If ‘Yes’, please complete fully the remainder of this section.
D D MM Y Y Y Y
D D MM Y Y Y Y
If you are a sole trader, we accept your PPS number as your business registration number.
Part 3 Your payment details
If you want to get your payment direct to your current, deposit or savings account
in a financial institution, please fill in your account details below. Alternatively, if
you want us to make your payment to your employer, please fill in your employer’s
account details and sign the declaration below (payments can only be made to
accounts held in the Republic of Ireland).
I authorise the Department of Social Protection to pay my Maternity Benefit to my employer’s
account in a
financial institution
.
Signature (not block letters)
Payment direct to my employer
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):
You will find the following details printed on statements from your
financial institution.
Please state clearly who you wish your payment to issue to.
This payment should issue to: You OR Your employer
Employer’s information Part 4
30.What is your employee’s
full name?
31.Please confirm their PPS
No.:
32.Please confirm the date
employee first started
working for you:
D D MM Y Y Y Y
D D MM Y Y Y Y
D D MM Y Y Y Y
34.Please give details of your employee’s PRSI record for the 12 month period immediately
before her maternity leave starts (e.g. If your employee’s maternity leave is due to start on
06/07/2015, you should provide her PRSI details for the period 06/07/2014 to 05/07/2015). The
forecasting of contributions is acceptable for any period after the 24th week of pregnancy.
35.If your employee has more than one class of PRSI (for example, if their PRSI changed from
Class A to Class J), please give details.
Period of
employment:
From:
To:
Number of weeks:
PRSI class:
Period of
employment:
From:
To:
Number of weeks:
PRSI class:
33.Please give full details of your employee’s maternity leave dates.
D D MM Y Y Y Y
From:
To:
Employer’s section continued overleaf
Your employer should only complete this section after your 24
th
week of pregnancy.
Note for Employer:
To qualify for the maximum 26 weeks Maternity Benefit, an employee must take
at least 2 weeks and at most 16 weeks leave before the end of the week in which
her baby is due. If your employee wishes to take the minimum 2 week period of
maternity leave prior to the birth of her baby, she should commence her
maternity leave on the Monday prior to the week in which her baby is due.
For example, if the due date is Wednesday 14/10/2015, the latest date the
employee should commence maternity leave is Monday 05/10/2015.
Employer’s information Part 4 continued
Warning: If you make a false statement or withhold information, you may be
prosecuted leading to a fine, a prison term or both.
Employer’s telephone
number:
Empl
oy
e
r’
s
e
mai
l
addre
ss:
If you make any alterations after you complete the form, you must initial and
date them otherwise the information supplied cannot be accepted.
M O B I L E
L A N D L I N E
Employer’s Contact Details
PRSI class:
D D MM Y Y Y Y
D D MM Y Y Y Y
I/We certify that the employee is entitled to the period of maternity leave stated above.
Signature (not block letters)
Employer’s official stamp
Position in company or organisation
Date:
2 0
Your name (IN BLOCK LETTERS)
36.Please confirm the date your employee was last present in the workplace and the class of
PRSI paid on that date:
Employer’s registered
number:
Details of your child(ren)Part 5
under age 18
age 18 - 22 in full-time education*
* You must attach written confirmation from the school or college
for the children aged 18 - 22
38.Please state child’s:
Surname:
PPS No.:
First name(s):
Surname:
PPS No.:
First name(s):
Surname:
PPS No.:
First name(s):
Surname:
PPS No.:
First name(s):
Note: A separate sheet of paper can be used for more details if needed.
37.How many children do you currently have who normally live with you and who are being
supported by you (this does not include any unborn child(ren))?
