Fillable Printable Disability Allowance Application Form
Fillable Printable Disability Allowance Application Form
Disability Allowance Application Form
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 let us know your mobile phone number and we will text you right away
confirming that we received your application.
If you do not have a spouse, civil partner or cohabitant
:
Fill in Parts 1 to 6 and 10. You should sign Part 11 confirming that you allow your
doctor to give us the medical information needed to decide if you qualify for
Disability Allowance. When form is completed, read Part 9 and sign declaration
in Part 1.
If you have a spouse, civil partner or cohabitant
:
Fill in Part 1 to 8 and 10. You should sign Part 11 confirming that you allow your
doctor to give us the medical information needed to decide if you qualify for
Disability Allowance. When form is completed, read Part 9 and sign declaration
in Part 1.
Doctor
:
Please fill in the medical report at Part 12. 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
Disability Allowance
DA 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(s) as
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 (person who is disabled or ill)
DA 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
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(s) as appears
on your birth certificate
:
8. Your
m
othe
r’s
b
irth
surna
m
e:
D D MM Y Y Y Y
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.
Page 1
21D40862
County Postcode
Warning: If you make a false statement or withhold information, you may be
prosecuted leading to a fine, a prison term or both.
1642642B
Application form for
Disability Allowance
5534164D
Your own details (person who is disabled or ill)
Part 1 continued
Your work and claim details Part 2
If your work is considered to be of a rehabilitative nature, please attach medical evidence.
14.Do you live on an island
off the coast of Ireland?
Yes
No
If ‘Yes’, please state:
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.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)
Name of this island:
Employer’s name:
Employer’s address:
15.Are you employed at
present?
Yes
No
If ‘Yes’, please state:
Gross weekly
earnings:
Please attach 3 of your most recent payslips.
a week
€ , .
Page 2
EDEA48EE
Disability 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 even if you are
not claiming an increase for a qualified adult.
6A60592E
Your work and claim details Part 2 continued
16.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
€ , .
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 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
17.Are you getting any other pension or allowance from the Republic of Ireland or from
another country?
Page 3
4FA7C0CD
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:
3257324A
Your work and claim details
Part 2 continued
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
FÁS course or schemes: 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
Page 4
20(b). Please state what you get paid for doing this scheme or course:
a week
€ , .
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:
,
03215C2D
362B1194
Your work and claim details Part 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
Page 5
Name of financial institution:
Current balance:
Financial Institution 1
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.
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):
D0AD6ADE
261BAD02
Your work and claim details
Part 2 continued
23.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.
€ , .,
24.Are you receiving
maintenance?
Amount:
Yes
No
If ‘Yes’, please state:
a week
€ , .
Please provide a copy of the maintenance agreement.
25(a). Have you made or do you intend to make a claim for compensation?
Yes No
If ‘Yes’, please give details in the space provided:
If you are receiving maintenance, please state the amount of mortgage or rent that you pay a week:
Amount: a week
€ , .
Please attach a statement from body, agency or rent receipt from
your landlord.
Page 6
FC0D240D
04456268
Yes No
Your work and claim details Part 2 continued
27.Did you sell or transfer property or business in the last three years?
26.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:
28.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.
25(b). 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:
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061C1BF2
C59FE75D
Habitual Residence condition
Part 3
Yes No
29.What country were you
born in?
30.What is your nationality?
32.Have you lived outside the Republic of Ireland for any period longer than three months
within the last five years?
31.When did you come to
live in the Republic of
Ireland?
D D MM Y Y Y Y
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:
Country:
Country 2
From:
To:
D D MM Y Y Y Y
Why you lived there:
For official use only
HRC not satisfiedHRC satisfied HRC1 issued
Page 8
07399BFA
A67F06DA
Your payment detailsPart 4
Page 9
Post office name and address:
Post Office
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. An account must be in your name or jointly held by
you. Please complete one option below.
Financial Institution
You will find the following details printed on statements from your financial institution.
If you are unable to collect or cash your payment at the post office and you want someone else
(known as an agent) to do so for you, please complete the following:
Your agent’s name:
Your agent’s address:
Your Signature (not block letters)
Date:
D D MM Y Y Y Y
2 0
Signature of agent (not block letters)
Date:
D D MM Y Y Y Y
2 0
I agree to act as agent for the person named in Part 1 and I am aware of my obligations.
For more information, log on to
www.welfare.ie
.
Name of financial institution:
Address of financial
institution:
Bank Identifier Code (BIC):
International Bank Account
Number (IBAN):
Name(s) of account holder(s):
Name 1:
Name 2 (if any):
Please enter below the name and address of the post office where you wish to collect your
payment.
4A6D8A56
