Application form for

Social Welfare Services Office

Household Benefits Package
For Departmental official use only

HB 1

Date received

Client No. TR
Intls.

Pen. Status EL PH TV LAA
Date

QAA

CDA

• Please read information booklet SW107 before completing this application form. • Please use BLOCK LETTERS and place a tick () in the boxes provided. • Please use BLACK INK and complete all questions on the application form.

Part 1

Allowance(s) you are applying for
Please tick if you wish to apply for: Telephone Allowance Television Licence

Please tick one of the four options below: ( See SW 107 ) Electricity Allowance Gas Allowance Group Account Allowance Bottled Gas Allowance

Part 2
Please State 1. What is your full name? 2. What is your birth surname (your surname when you were born), if different? 3. What is your mother’s birth surname (her surname when she was born), if different? 4. Where do you live?

Your own Details
Mr. Last name First name(s) Mrs. Ms. Other

Address

5. What is your telephone number? 6. What is your date of birth? 7. What is your Personal Public Service Number (PPS No.)? 8. How long have you lived at this address? 9. Have you changed address recently? 10. If yes please give details of your previous address

Landline Day Month
Figures

Mobile Year
Letter(s)

Years
Yes No

Months

Part 2 continued
11. Have you or anyone in your household ever applied for Household Benefits?

Your own details

Yes

No

If yes, please state Name of applicant:
Figures Letter(s)

PPS Number:

Address at which application was made (if different from that given in Part 1) 12. Are you living alone?
Yes No

If No, please give details of those living with you. It is important to complete this fully and accurately as your claim cannot be processed without the information required.
Date of birth Name of person Day Month Year Source of income or How are they related other social welfare Gross pay if employed payment to you? PPS Number

Important: Attach a certificate from the school or college for dependent children, between ages 18 and 22, attending full-time education. 13. Are you getting a pension or allowance from Ireland or any other country?
Yes No

If Yes please state: Type of Payment: Source of payment: (for example, Department of Social & Family Affairs)

Claim Number: If your pension or allowance is from a country other than Ireland, OR you are in receipt of a private pension, AND you are under 70 years of age, documentary evidence from the agency paying your pension or allowance must be attached with your claim. Are you receiving a Carer’s Allowance from this Department?
Yes No

Part 3
1. Electricity or Gas Allowance:

You must complete relevant section below and also include a copy of recent bill(s) where relevant

You must be registered, or joint registered consumer, before the allowance can be credited to your bill. Please contact your supplier if this is not the case. What is your electricity MPRN? (11 digit number) on right hand side of bill OR What is your Gas GPRN? (7 digit number) on right hand side of bill Who is your supplier? 2. Group Account Allowance / Bottled Gas Allowance: For Electricity or Gas, if the registered consumer is a landlord, or you have a separate slot meter, you may be entitled to a Group Account Allowance. If your home is not connected to an electricity or gas supply you may get a Bottled Gas Allowance. These allowances will be paid monthly to your nominated financial institution or post office. Please refer to booklet SW 107 If you are applying for a Group Account Allowance or Bottled Gas Allowance please tick below how you wish to be paid: To your nominated financial institution To your Post Office (using Social Services Card) (please attach copy of recent bill) (please attach copy of recent bill)

(You must complete payment details at PART 4 overleaf) 3. Telephone Allowance: Please tick whether you want the allowance to apply to a landline phone (the allowance will be credited to your bill) or to a mobile phone (your allowance will be paid monthly to your nominated financial institution or post office). Please refer to booklet SW 107 Landline Phone (If landline phone please attach copy of recent bill) Telephone Number: If landline, who is your supplier? If mobile phone, please tick below how you wish to be paid: To your nominated To your Post Office financial institution (using Social Services Card) (You must complete payment details at PART 4 overleaf) 4. Television Licence: What is your television licence number? (Attach copy of TV licence) Mobile Phone

Part 4

Your payment details

You must complete your preferred payment details if you have applied for a mobile phone allowance and / or group account allowance or bottled gas allowance. 1. Direct payment to your account: Name of financial institution: Address:

Name on the account: (must be in your name or joint account) Sort code (you can get this from your branch): Account Number (8 digits): OR Post Office Payment using Social Welfare Services Card:

2.

Name of Post Office: Address:

Do you require a Social Welfare Services Card?

Yes

No

Part 5

Declaration

I declare that all of the details I have given are true and I am permanently living at the address shown in Part 2 of this application form. I will tell you if there is any change in the details I have given, or if I no longer satisfy any of the qualifying conditions.
Signed Date

Send this completed application form and copies of recent bills to: Free Schemes Section Social Welfare Services Office FREEPOST College Road Sligo Telephone LoCall: 1890 500 000 ext. 48371 from the Republic of Ireland +353 71 9148371 from Northern Ireland or overseas If you need any help to fill in this form, please phone us in Free Schemes Section at the telephone numbers listed above or call to your local Social Welfare Office. Data Protection and Freedom of Information We, the Department of Social and Family Affairs, will treat all information and personal data you give as confidential. We will only disclose it to other people or bodies in accordance with social welfare law. We will be responsible for your information under the Data Protection Act and Freedom of Information Act.
Explanations and terms used in this form are intended as a guide only and do not purport to be a legal interpretation.
150K 03-07 Edition March 2007