Fillable Printable Carers Allowance Form Sample
Fillable Printable Carers Allowance Form Sample
Carers Allowance Form Sample
You need a Personal Public Service Number (PPS No.) before you apply.
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.
• Please do not strikethrough any of the boxes. Leave boxes blank if they do not
apply to you.
You should apply for Carer’s Allowance as soon as you start caring for someone.
If you do not have a spouse, civil partner or cohabitant
:
If you do not have a spouse, civil partner or cohabitant, fill in Parts 1 to 5 and
Part 8. When the form is completed, read Part 9 and sign declaration in Part 1.
If you have a spouse, civil partner or cohabitant
:
If you have a spouse, civil partner or cohabitant, fill in Parts 1 to 8.
When the form is completed, read Part 9 and sign declaration in Part 1.
carer
:
Please complete Section a in Part 10 of the medical report and get the person
you are caring for to sign Section a in Part 10 of the medical report.
Doctor
:
Please fill in Section b in Part 10 of the medical report. Please make sure you
sign and stamp this part of the form.
If you need any help to complete this form, please contact your local Citizens
Information Centre, your local Intreo Centre or your local Social Welfare Office.
For more information, log on to www.welfare.ie.
Application form for
Carer’s Allowance
CR 1
Social Welfare Services
Data Classification R
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
L A N D L I N E
M O B I L E
2 8 0 2 1 9 7 0
O N E C H A R A C T E R P E R
B O X
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
:
10.Y
our telephone number:
11.Your email address:
Contact Details
9. Your address:
X
M A R Y
8. Your mother’s birth
surname:
K E L L
Y
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 Postcode
Part 1
Your own details (carer’s Details)
CR 1
Social Welfare Services
Data Classification R
Signatur
e (no
t block let
ters)
Date:
D D M M Y Y Y Y
2
0
Declaration
10. Y
our telephone number:
11. Your email address:
Contact Details
9. Your address:
M O B I L E
L A N D L I N E
Warning: If you make a false statement or withhold information, you may be
prosecuted leading to a fine, a prison term or both.
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.
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
m
othe
r’s
b
irth
surna
m
e:
D D MM Y Y Y Y
Application form for
Carer’s Allowance
Signatur
e of w
itness (no
t block let
ters)
Date:
D D M M Y Y Y Y
2
0
If you cannot sign your name, make a mark, such as an X and have it witnessed.
County Postcode
Page 1
6A44CF86
A699208E
3861BE0A
Your own details (carer’s Details)
Part 1 continued
Your work and claim detailsPart 2
Type of work:
13.If you are married, in a civil partnership or cohabiting, from what date?
D D MM Y Y Y Y
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)
Employer’s name:
Employer’s address:
15(a). Are you employed at present?
Yes
No
If ‘Yes’, please state:
Gross weekly
earnings:
Please attach 3 of your most recent payslips.
a week
€ , .
Carer’s Allowance is a means tested payment. You are legally obliged to declare all your
means which include money in cash or in a financial institution, savings, shares, bonds,
funds, property (other than your own home), foreign pensions etc. Please include written
evidence such as statements and payslips with your application. Failure to do so could
result in a delay in processing your application.
You must also declare the means of your spouse, civil partner or cohabitant.
15(b).
You can work for up to 15 hours a week outside the home. Do you intend to....?
or
(a) remain at work for up to 15 hours a week:
(b) return to work for up to 15 hours a week:
Yes
No
Yes No
Page 2
14.If you previously lived or worked in the UK, please state your UK Social Security Number:
CF3CC584
051E5DE9
Your work and claim detailsPart 2 continued
Who pays this pension:
Your claim or reference
number:
Amount:
Please attach the most recent payslip or letter from the people who pay you confirming the above
amount and also provide a 6 month bank statement for the account to which this payment is made.
Yes
No
If ‘Yes’, please state:
a week
€ , .
18.Are you getting any other pension or allowance from the Republic of Ireland or from
another country?
17.Are you getting a social security payment from another country?
Name of country:
Your claim or reference
number:
Amount:
Please attach the most recent payslip or letter from the Social Security Agency confirming the above
amount and also provide a 6 month bank statement for the account to which this payment is made.
Yes
No
If ‘Yes’, please state:
a week
€ , .
Page 3
16.Are you or have you been self-employed?
Type of work you do/did:
Net yearly earnings: a year
€ .,
This is the money you have made from self-employment after deducting operating expenses.
Yes
No
If ‘Yes’, please state:
Dates of self-
employment:
From:
To:
D D MM Y Y Y Y
19(a). Do you own, share in the ownership, work or rent a farm or land?
Size of farm or land:
acres
Net yearly income
or rent from farm
or land:
€ .,
‘Net yearly income’ is money you have made from the farm after
deducting operating expenses.
Yes No
If ‘Yes’, please state:
Herd or flock number:
19(b). If your farm or land is let, please state net yearly income from letting:
€ .,
Net yearly income:
610BB3F2
C49EB85F
Part 2 continued Your work and claim details
20(a). Are you taking part in any of the following courses or schemes, insert an X in the box
as it applies to you and give the date you started if you insert an X in the Yes box.
Community employment: Yes
No
D D MM Y Y Y Y
Date you started:
Rural Social Scheme: Yes
No
D D MM Y Y Y Y
Area-Based Initiative: Yes No
D D MM Y Y Y Y
Back to Work Scheme: Yes No
D D MM Y Y Y Y
Vocational Training
Opportunities Scheme:
Yes
No
D D MM Y Y Y Y
Back to Education
Allowance:
Yes
No
D D MM Y Y Y Y
Yes No
D D MM Y Y Y Y
School or college: Yes No
D D MM Y Y Y Y
Other course or scheme:
Yes No
If ‘Yes’, please state:
Name of course or scheme:
Date you started: From:
To:
D D MM Y Y Y Y
20(b). Please state what you get paid for doing this scheme or course:
a week
€ , .
Page 4
Solas/FÁS course or schemes:
21.Do you own stocks, shares (including shares in a creamery or Co-op, annuities, bonds,
insurance policies) or investments in the Republic of Ireland or another country?
Their value:
Please attach a statement to show details and current market value.
Yes
No
If ‘Yes’, please state:
€ .,
Name of company:
Number of shares held:
,
DBFF1A5B
188D9540
Your work and claim detailsPart 2 continued
22.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):
Page 5
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):
Name of financial institution:
Current balance:
Financial Institution 3
€ .,
International Bank
Account Number (IBAN):
Is this account a joint account?
Yes
No
Bank Identifier Code (BIC):
3267150E
F63D760E
Part 2 continued Your work and claim details
Please attach an original statement for each account, showing transactions for the last 3
months.
If you have any other accounts you must give details of them to this Department on a
separate sheet of paper.
Financial Institution 3 continued
Name(s) of account holder(s):
Name 1:
Name 2 (if any):
Page 6
23(a). Do you own or share in the ownership of property apart from your home?
Type of property:
Address of property:
‘Property’ would be an
apartment, business
property, another
house or land other
than that mentioned at
question 19.
€ , .,
Current market value:
Yes No
If ‘Yes’, please state:
a week
€ , .
Rent from this
property:
Please provide a valuation from an authorised auctioneer or valuer.
Outstanding
mortgage on
property:
If mortgaged please attach a recent statement from lending institution.
Note: A separate sheet of paper can be used for details of any additional properties that
you have.
€ , .,
DEA58676
Weekly income:
23(b). If you have a room let in the property you are currently residing in, please state:
a week
€ , .
24.Are you receiving
maintenance?
Amount:
Yes
No
If ‘Yes’, please state:
a week
€ , .
Please provide a copy of the maintenance agreement.
25.Are you paying
maintenance?
Amount:
Yes
No
If ‘Yes’, please state:
a week
€ , .
Please provide a copy of the maintenance agreement.
0ABD57BC
Your work and claim detailsPart 2 continued
Page 7
Yes No
28.Did you sell or transfer property or business in the last three years?
27.Do you have any other income from the Republic of Ireland or another country?
Yes No
If ‘Yes’, please give details in the space provided:
Yes No
If ‘Yes’, please give details in the space provided and attach a copy of the deed of transfer:
26.Do you expect to receive any additional income or money in the coming 12 months from
any other source(s) (that is for example a claim for compensation arising out of an
accident/injury, sale of property, etc.)?
If ‘Yes’, please give details in the space provided:
B4A6DB4A
29.Did
you recently sell your home to buy another?
Yes No
If ‘Yes’, please outline the circumstances in the space provided and attach supporting
documentary evidence from your solicitors regarding the financial transaction.
7B9951E8
Part 3 Habitual Residence condition
Page 8
30.What country were you
born in?
31.What is your nationality?
32.When did you come to
live in the Republic of
Ireland?
D D MM Y Y Y Y
Yes No
33.If you are not an EEA National, do you hold a current:
Irish Residence Permit
(Stamp 4):
Yes
No
Irish Employment Permit
(Stamp 1):
Yes
No
Student Visa (Stamp 1A,
Stamp 2A or Stamp 3:
Other?
Yes
No
If ‘Yes’, please give details in the space provided.
If ‘Yes’, to any of the above, please enclose your original permit and your original letter from
the Department of Justice which sets out the reasons you have been granted permission to
reside in the Republic of Ireland.
34.Do you have a GNIB (Garda National Immigration Bureau) card?
If ‘Yes’,
please attach a verified copy of same (your local Intreo Centre or your local Social
Welfare Office can photocopy it for you and verify that they saw the original).
Yes
No
The European Economic Area (EEA) comprises of the member states of the European Union
together with Iceland, Norway and Liechtenstein and Croatia.
08BC0E6B
1649D90E
Habitual Residence conditionPart 3 continued
Yes No
36.Have you lived outside the Republic of Ireland for any period longer than three months
within the last five years?
If ‘Yes’,
please give details of where you lived in the space provided
.
Country:
Country 1
From:
To:
D D MM Y Y Y Y
Why you lived there:
Page 9
35.How long do you intend to stay in the Republic of Ireland?
0-1 year
1-2 years
3-5 years over 5 years
Country:
Country 2
From:
To:
D D MM Y Y Y Y
Why you lived there:
FB6CC4B8
