Fillable Printable Job Seekers Benefits or Allowance Form
Fillable Printable Job Seekers Benefits or Allowance Form
Job Seekers Benefits or Allowance Form
Single Married Widowed In a Civil Partnership
Separated Divorced Cohabiting
VERIFIED ( Y / N )
PART 1
PERSONAL DETAILS about you and your spouse, civil partner or cohabitant
DAY MONTH YEAR
FIGURES
LETTER
(S)
F
IGURES
LETTER(S)
VERIFIED ( Y / N )
DAY
MTH YR
DAY
MTH YR
Jobseeker’s Allowance or
Benefit
Application form for
UP 1
1. Please state:
• Personal Public Service Number
(PPS.no.)same as RSI/Tax Number
• First name(s)
• Surname
• Birth surname if different
• Address
(If you and your spouse, civil partner or
cohabitant are not living together give
both
Addresses)
• How long have you lived at this
address?
• Telephone/Mobile Number
If you enter your mobile number we may
text you in connection with your claim.
• Do you wish to avail of this service?
• Email address:
• Mother’s birth surname
• Distance from nearest Intreo Centre
or Social Welfare Local/Branch Office
• Nationality
• Your normal occupation
• Your last occupation
• Date of Birth
Attach your Birth Certificate
2. Are you?
• Date of marriage/civil partnership
If you are separated from your spouse,
civil partner or cohabitant please state:
• Amount of maintenance paid by you
• Date you last paid maintenance
3. Payment Details:
Give details of the Post Office at which
you wish to receive your payment.
APPLICANT Male/Female
A. POST OFFICE details
State NAME of POST OFFICE:
• Please answer ALL questions, except Part 2 in the case of JB claims, and place a tick ( ✓ ) in the boxes provided.
• Please use BLOCK LETTERS.
Intreo Centre/Social Welfare Local Office
ID Known
ID File Ph
ID Pass
ID DL
ID Other
S
cheme
C
omm
UP 20
Advised
about
Credits
PO Code
Occ
€
POST OFFICE details
per week/month
Male/Female
SPOUSE, CIVIL PARTNER
OR COHABITANT
VERIFIED ( Y / N )
DAY MONTH YEAR
YES NO YES NO
FOR
OFFICIAL
USE ONLY
4. In what country were you
born?
5. What is your nationality?
6. Have you lived in the Common
Travel Area all of your life?
If ‘Yes’, please complete
questions 11 and 12.
If ‘No’, please complete
questions 7 to 12.
7. Have you lived in the Common
Travel Area for the last 2
years?
If ‘No’, please give details
below about each country
outside the Common Travel
Area where you have lived:
8. When did you come to
Ireland?
Have you lived continuously
in Ireland since the day you
arrived?
Country From
Why you lived there
To
DAY
MTH
YR
Note
The Common Travel Area is Ireland, Great Britain, the Isle of Man and the Channel
Islands.
You can spend brief periods on short holidays, studying or travelling outside the
Common Travel Area and still be habitually resident here.
Habitual residence is a condition that you must satisfy to qualify for Jobseeker’s
Allowance. See SW 108 for more information about habitual residence.
HABITUAL RESIDENCE CONDITION
PART 2
YES NO
YES NO
YES NO
Relationship
to you
When they came
to Ireland
Name
10. Have you ever made an
application for Refugee
Status?
If ‘Yes’, please answer
questions 10(a) and 10(b)
and give copies of all
relevant documents from the
Department of Justice and
Equality.
(a) Are you waiting for a
decision on an application
for Refugee Status?
(b) Have you been granted
Refugee Status or leave to
remain in the State on other
grounds?
11. Please state where you lived
in the Common Travel Area.
12. Have you lived at the same
address for the last 2 years?
If ‘No’, please give details of
previous addresses:
Ireland Great
Britain
Isle of Channel
Man Islands
For Official Department use only.
HRC satisfied HRC not satisfied HRC1 issued
Last address
Previous address
To
From
From
9. Does any of your close family,
for example parent, brother,
sister or child, live in Ireland?
If ‘Yes’, please give their
details.
PART 2 (CONTD.)
HABITUAL RESIDENCE CONDITION
DATE OF BIRTH
Day Month Year
Address
To
YES NO
YES NO
YES NO
YES NO
YES NO
EMPLOYMENT DETAILS
I worked hours per day
If ‘YES’, please attach to this claim form.
DAY MTH YR
I worked days per week
DAY
MTH YR
DAY
MTH YR
13. Please state:
• Your last Employer’s Name
• Address of employer
• Occupation
• Dates of Employment
FROM
TO
• Work pattern
14. Why did your employment
end?
15. Did you get a P45?
16. a) Did you get a redundancy
payment?
If ‘YES’, please state:
•Amount
•Date received
b) Did you get redundancy
form RP50?
17. a) Have you had other employment in
Ireland in the last 2 years?
If ‘YES’, please state:
•Name of employer
•Address of employer
b) Have you had other employment in
another EU country in the last 2
years?
If ‘YES’, please state:
•EU country
•Social Security No./European
Number
18. Is anyone claiming for YOU as
a qualified adult on their Social
Welfare payment?
If ‘YES’, please state:
• Type of payment
• Their name
• Weekly amount
• Their PPS number
If ‘YES’, please attach to this claim form.
€
€
PART 3
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Hours per day
Days per week
YES NO
€ per week/month
€ per week
PART 4
DETAILS OF AVAILABILITY/WORK EFFORTS
YES NO
YES NO
YES NO
19. Please state:
• Type of work you are looking
for?
• Are you available for full-time
work?
• Are you looking for full-time
work?
• Number of hours work you
would accept?
• Would you accept any other type
of work?
If ‘YES’, give details:
• Where have you tried to get
work? Please attach any
documentary evidence.
20. Are you at present:
a) Self-Employed, including
farming?
b) Working Part-time?
c) On a Community
Employment Scheme?
d) On a Solas or Local
Employment Services
course?
If ‘YES’, to a, b, c, or d please
state:
• Employer’s Name
• Type of work you do
• Hours of work
• Amount of income/earnings
21. Are you currently registered
with any school, college or
university?
If ‘YES’, state:
• Name of college
• Course name
• Hours of attendance
• When will course end?
• What type of student are you
registered as?
Do you intend to resume
college education in the
coming academic year?
If ‘YES’, please state:
• Type of payment
• Claim number
• Amount
• Source of payment
• Country of payment
23. Do you wish to claim for a
spouse, civil partner or
cohabitant?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO N/A
22. Are you getting or have you recently applied for any social welfare (including FIS)/social security payments from this Department,
from any other EU member state, from another agency or from a private source such as a pension provider?
DAY
MTH
YR
If ‘YES’, please give details of their
hours/days worked each week
b) Their gross weekly income
c) Does he/she hold any (including
joint) bank accounts,
investments, property or capital?
If ‘YES’ please provide details
Any other income?
25. Is your spouse, civil partner or
cohabitant on a:
a) Solas Course?
b) Community Employment
Scheme?
c) Back to Work Scheme?
d) Back to Education Allowance?
e) Education and Training Board
course?
f) Other, please specify
If ‘YES’, to any of the above,
please state:
• Type of course/scheme
• Start date
• Amount of payment
26. Is your spouse, civil partner or
cohabitant ‘signing’ for or claiming:
a) Jobseeker’s Benefit?
b) Jobseeker’s Allowance?
c) ‘Credits’?
d) Any other Social Welfare
payment? (apart from Child
Benefit)
If ‘YES’, please state:
• Type of payment(s)
• PPS number
If ‘YES’, please state:
• Country of payment
• Type of payment
• Amount of payment
• Address of issuing office
• Social security number
If ‘YES’, please state:
• Source of income
• Weekly amount
€ per week
€ per week
€ per week
Spouse, Civil Partner or Cohabitant’s Income/Social Welfare Details
Hours a day
YES NO
YES NO
YES NO
YES NO
YES NO
FIGURES
LETTER
(S)
PART 5
Days per week
YES NO
€ per week
€ per week
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
24. a)Is your spouse, civil partner or cohabitant in employment or self-employment including farming?
27.Is your spouse, civil partner or cohabitant getting any social security payment from the UK or any other EU country?
28.Is your spouse, civil partner or cohabitant getting any other income?
29a.Do you wish to claim for any
child dependants?
If ‘YES’, please complete
questions 29b to 32.
If ‘NO’, please proceed to
question 33
29b.Children under age 18:
30. Children over age 18 and in
full-time education ( JA/JB claims
over 156 days):
A written statement from the
school or college should be
attached for any child aged
between 18 and 22 in full-time
education.
31. In the case of child(ren) listed at
29b) and 30) above who are not
living with you please state with
whom the child(ren) live:
• Amount of maintenance paid by
you or your spouse, civil partner
or cohabitant (if any):
32. Are any of the children getting
a payment in their own right,
or is a payment being made
to another person on their
behalf?
33. If you did not claim as soon
as you became unemployed
a) Do you wish to have your
claim back-dated?
b) If ‘YES’, please state the
reason for delay here:
PART 6
QUALIFIED CHILD(REN) DETAILS
Child’s
First Name
Child’s
Surname
DATE OF BIRTH
Day Month Year
Relationship
to you
Does the
child live
with you?
LIST CHILDREN HERE, SHOWING ELDEST CHILD FIRST:
LIST ADDITIONAL CHILDREN ON A SEPARATE SHEET OF PAPER.
Child’s
First Name
Child’s
Surname
DATE OF BIRTH
Day Month Year
Relationship
to you
Does the
child live
with you?
€
PART 7
per week/month
LATE CLAIMS
You cannot get paid for a child who is getting a Social Welfare payment in their own right or if a
Guardian’s payment is being paid for them
YES NO
YES NO
YES NO
Warning: If you make a false statement or withhold information, you may be prosecuted
leading to a fine, a prison term or both.
Please bring this completed application form to
your local Intreo Centre, Social Welfare or Branch
Office when you attend to make your claim.
OPTIONAL JOBSEEKER’S ALLOWANCE
PART
8
34.Do you wish to apply for
optional Jobseeker’s Allowance if
you do not qualify for the full rate
of Jobseeker’s Benefit?
DECLARATION
PART
9
The Department of Social Protection will shortly be issuing SMS text messages as a
means of contacting you regarding your claim. We will need your mobile phone
number to allow us to do this. Please see Part 1 for details and ensure you give us
your mobile phone number and indicate if you wish to avail of this service.
Edition: February 2015
Data Protection Statement
The Department of Social Protection will treat all information and personal data you give us as
confidential. However, it should be noted that information may be exchanged with other
Government Departments / Agencies in accordance with the law.
Explanations and terms used in this form are intended as a guide only and are not a legal interpretation.
YES NO
(NOT block letters)
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.
If you are not able to sign, your mark should be made and witnessed. The witness should sign below.
I hereby claim Jobseekers Benefit/Allowance. I declare that,
a) I am unemployed and unable to get suitable full-time work
b) I am capable of, available for and genuinely seeking work
c) I have not claimed nor am I getting any other benefit, pension or allowance from any
source apart from those shown in this form
d) I will notify the Department if I get work.
YOUR SIGNATURE
DATE
WITNESS SIGNATURE
DATE
ADDRESS OF
WITNESS
NAME OF
WITNESS
