Fillable Printable Application Form for Supplementary Welfare Allowance Rent Supplement
Fillable Printable Application Form for Supplementary Welfare Allowance Rent Supplement
Application Form for Supplementary Welfare Allowance Rent Supplement
You need a Personal Public Service Number (PPS No.) before you apply.
How to complete this application form.
• Please tear off this page and use 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. We will return any form that is incomplete. This
will delay your application for Supplementary Welfare Allowance.
If you do not have a spouse, civil partner or cohabitant:
Fill in Parts 1, 3, 4, 7, 8 and 9 as they apply to you. When form is completed,
read Part 10 and sign declaration in Part 1.
If you have a spouse, civil partner or cohabitant:
Fill in Parts 1, 3, 4, 5, 7, 8, and 9 as they apply to you and your spouse, civil
partner or cohabitant. When form is completed, read Part 10 and sign
declaration in Part 1.
Employer:
If you are an employer for the applicant fill in Part 2. If you are an employer
for the spouse, civil partner or cohabitant fill in Part 6. Please make sure you
sign and stamp these parts of the form.
Landlord or landlord’s agent:
Please fill in Part 11. Please make sure you sign and stamp this part of the form.
Please note:
To process your Rent Supplement, we need to establish ownership of the
property by the landlord. One of the following documents are acceptable in
photocopy form.
1. Evidence of registration with Private Residential Tenancies Board (PRTB).
2. Receipt from Non Principal Private Residence (NPPR).
3. Evidence of buildings insurance policy held by landlord.
If you need any help to complete this form, please contact your local Intreo
Centre, Social Welfare Office or Citizens Information Centre.
For more information, log on to www.welfare.ie.
SWA RS 1
Social Welfare Services
Data Classification R
Application form for
Supplementary Welfare Allowance
Rent Supplement
How to fill 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
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:
7. 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
:
Contact Details
X
M A R Y
8. 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:
9. Your 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
County D O N E G A L
Post Code
10.Y
our telephone number:
11.Y
our
email address:
9. Y
our
address:
Contact Details
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.
Signature (not block letters)
Date:
D D MM Y Y Y Y
2 0
Declaration
Warning: If you make a false statement or withhold information, you may be
prosecuted leading to a fine, a prison term or both.
L A N D L I N E
M O B I L E
Part 1 Your own details
1. Your PPS No.:
3. Surname:
7. 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
:
8. Your mother’s birth
surname:
D D MM Y Y Y Y
SWA RS 1
Social Welfare Services
Data Classification R
For Official Use Only
Date received
By whom
Application form for
Supplementary Welfare Allowance Rent Supplement
County
Post Code
If you are married, in a civil
partnership or cohabiting,
from what date?
D D MM Y Y Y Y
Your own detailsPart 1 continued
12.A
re 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)
Are you employed?
You are ‘employed’ when you work for another person or company and you get paid for this work.
Please attach copies of your 4 most recent payslips.
Yes
No
Your current employer’s
name:
Your current employer’s
address:
Your usual occupation:
If ‘Yes’, please state:
Your current employer must also complete Part 2.
13.Your current income
from employment:
a week
€ , .
Your last employer’s name:
Your last employer’s
address:
Your last occupation:
If ‘No’, please state:
Your previous income: a week
€ , .
a week
Number of days worked
a week:
Total
number of hours
worked per week:
a week
Date you were last
employed:
D D MM Y Y Y Y
County
Post Code
County
Post Code
Your own detailsPart 1 continued
14.Amount of redundancy
payment made and
date paid?
D D MM Y Y Y Y
Please attach original written confirmation of redundancy.
€ .,
18.If you are getting or have applied for any payment(s) from this Department or from the
Health Service Executive, please state:
Name of payment:
Amount:
19.If you are getting or have applied for any other pension or allowance from another country,
please state:
Name of country:
Amount:
Note: A separate sheet of paper can be used for more details if needed.
20.Have you applied for any other source(s) of income such as an occupational pension?
Type of payment:
Amount:
a week
€ , .
a week
€ , .
a week
€ , .
Your claim or reference
number:
16.If you are self-employed (including farming) at present, please state:
Your profit over the
last year:
€ , .
Type of business or trade:
Note: Please attach your profit and loss account for the last 12 months, together with most
recent notice of assessment from Revenue Commissioners.
17.Are
you?
In full-time education
Involved in an industrial dispute
Yes No
If ‘Yes’, please state:
15.Amount and date of
redundancy payment
due?
D D MM Y Y Y Y
€ .,
Yes No
21.Do you have any other income including but not limited to income from casual, occasional or
seasonal employment?
If ‘Yes’, please give details in the space provided:
Your own detailsPart 1 continued
23.Do you have savings or accounts in a bank, post office, building society, credit union or any
other financial institution in the Republic of Ireland or another country?
Yes
No
Name of financial institution:
Current balance:
Financial Institution 1
If ‘Yes’, please state:
€ .,
International Bank
Account Number (IBAN):
Name(s) of account holder(s):
Name 1:
Name 2 (if any):
Is this account a joint
account?
Yes
No
Bank Identifier Code (BIC):
Name of financial institution:
Current balance:
Financial Institution 2
€ .,
International Bank
Account Number (IBAN):
Name(s) of account holder(s):
Name 1:
Name 2 (if any):
Is this account a joint
account?
Yes
No
Bank Identifier Code (BIC):
22.If you are getting or have applied for maintenance, please state:
Amount: a week
€ , .
Your own detailsPart 1 continued
24.Do you own stocks, shares (including shares in a creamery or Co-op, annuities, bonds,
insurance policies) or investments?
Their value:
Yes
No
If ‘Yes’, please state:
€ .,
Yes No
25. Do you own or share in the ownership of any property (including land) other than the house you occupy?
Use of property/land:
If ‘Yes’, please state:
Property/land address:
26.How much are you paying weekly on the following?
House rent:
Cost of travel to work:
a week
€ , .
a week
€ , .
Note: A separate sheet of paper can be used for more details if needed.
Mortgage:
a week
€ , .
Maintenance you pay:
a week
€ , .
Please attach a statement to show
details and current market value.
County
Post Code
Please attach an original statement for each account, showing transactions for the last 6 months.
If you have any other accounts you must give details of them to this Department on a
separate sheet of paper.
Note: A separate sheet of paper can be used for more details if needed.
Name of financial institution:
Current balance:
Financial Institution 3
€ .,
International Bank
Account Number (IBAN):
Name(s) of account holder(s):
Name 1:
Name 2 (if any):
Is this account a joint
account?
Yes
No
Bank Identifier Code (BIC):
Details from your current employerPart 2
33.Gross basic wage per
hour:
€ .,
34.Gross income since
January 1st last:
€ .,
35.Number of weeks of
insurable employment
since January 1st last:
36.PRSI contributions
deducted since
January 1st last:
€ .,
37.Total Tax (PAYE) paid
since January 1st last:
€ .,
Employee on sick leave
38.Is the employee on sick
leave from your firm?
Yes
No
39.What date did sick leave
commence?
D D MM Y Y Y Y
per hour
40.Gross weekly amount
of sick pay less PRSI:
€ .,
a week
41.Date of last payment
made:
D D MM Y Y Y Y
42.Amount of last
payment made:
€ .,
Yes No
This part must ONLY be completed by your employer
27.What is your employee’s
full name?
28. Please confirm their PPS No.:
29.Their address:
Current employee
30.Please confirm the date
employee first started
working for you:
D D MM Y Y Y Y
31.Is the above employee participating in a Department of Social Protection Employment
Incentive Scheme?
32. Numbers of hours normally
worked per week?
a week
County
Post Code
Details from your current employerPart 2 continued
Signed by or for employer
Signature (not block letters)
Employer’s official stamp
Position in company or organisation
Date:
D D MM Y Y Y Y
2 0
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:
M O B I L E
L A N D L I N E
Employer’s registered number:
Habitual Residence ConditionPart 3
43.
What country were you
born in?
44.
What is your nationality?
This section must be completed by all applicants. Habitual residence is a condition that you
must satisfy to qualify for this payment. For more information, log on to www.welfare.ie.
45.Do you have a social security number from another country?
Social security number:
Yes
No
If ‘Yes’, please state:
Country:
46.Do you have a
GNIB (Garda National Immigration Bureau) card
?
Yes
No
If ‘Yes’, please attach a verified copy of same (your local Social Welfare Office can photocopy
it for you and verify that they saw the original).
Yes
No
47.Have you resided continuously in Ireland since birth?
If ‘No’,
please give details of where you lived in the space provided
.
Country:
Country 1
From:
To:
D D MM Y Y Y Y
Country:
Country 2
From:
To:
D D MM Y Y Y Y
For official use only
HRC satisfied HRC1 issued
Why you lived there:
Why you lived there:
Details of your dependent child(ren)Part 4
48.How many children do
you have?
Please state child’s:
Surname:
PPS No.:
First name(s):
Note: A separate sheet of paper can be used for more details if needed.
Yes
No
Does this child live with you?
D D MM Y Y Y Y
Date of birth:
Surname:
PPS No.:
First name(s):
Yes
No
Does this child live with you?
D D MM Y Y Y Y
Date of birth:
Surname:
PPS No.:
First name(s):
Yes
No
Does this child live with you?
D D MM Y Y Y Y
Date of birth:
Surname:
PPS No.:
First name(s):
Yes
No
Does this child live with you?
D D MM Y Y Y Y
Date of birth:
Child 1
Child 2
Child 3
Child 4
under age 18
age 18 - 22 in full-
time education*
*You must attach written
confirmation from the school or
college for children aged 18 - 22
