4558149477
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1. Your PPS Number:
3. Surname:
6. Your date of birth:
4. First name(s):
5. Y
our birth surname
:
Contact Details
Application form for
Household Benefits Package
D D M M Y Y Y Y
8. Your address:
10. Your email address:
Signature (not block letters)
Date:
D D M M Y Y Y Y
Declaration
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.
9. Your
telephone number:
Part 1 Your own details
Mr Mrs Ms
Other
2.
Title: (insert an X or
specify)
HB 1
Social Welfare Services
Data Classification R
You need a Personal Public Service Number (PPS Number) before you apply.
• Please use BLACK ball point pen.
• Please use BLOCK LETTERS and place an X in the relevant boxes.
• Please answer all questions.
For more information, please visit www.gov.ie
Page 1
County
Postcode
2 0
12345678
7. Your mother’s
birth surname
:
Mobile
Landline
9893581979
98935819799893581979
9893581979
23456781
17. If you or anyone in your household has ever applied for Household Benefits, please state:
Applicant’s surname:
Applicant’s first name:
PPS Number:
Source of income
or social welfare
payment or student
14. Are you living alone?
Gross pay if
employed
15. Are you getting a private
or occupational pension?
Type of payment:
Source of payment:
13. Are you aged 70 years or over?
If Yes to either of the above, please state:
16. If you are aged between 66 and 70 years and not in receipt of a qualifying payment do you want
to be means tested? For more information visit www.gov.ie.
Are you getting a social security payment from another country?
11. Have you changed
address recently?
If Yes, please give
details of your previous
address
Part 1 continued Your own details
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
PPS NumberName
19. Are you legally entitled to reside in Ireland?
Yes
No
If you are a holder of an Irish Residence Permit (IRP) card, please provide a copy of the IRP card
and your letter from the Department of Justice.
18. What is your nationality?
Page 2
Yes No
If No, please give details of those living with you:
How are they
related to you?
12. Are you living permanently
in the State?
2571062463
25710624632571062463
2571062463
34567812
1. Electricity Allowance:
You must be registered, or a jointly registered consumer, that is your name must be on the bill,
before the allowance can be credited to your bill. Please contact your supplier if this is not the
case. Please provide a copy of your electricity bill.
What is your electricity
MPRN?
(11 digit number) on right hand side of bill
What is your Gas GPRN?
(7 digit number) on right hand side of bill
Who is your gas supplier?
3. 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 natural gas supply you may be entitled to a Bottled Gas Allowance. These allowances are paid
monthly to your nominated financial institution or post office.
For more information, please visit www.gov.ie
(You must complete payment details at PART 3 overleaf)
Please tick ONLY ONE of the four options below:
For more information, visit www.gov.ie
Electricity Allowance (complete question 1), or
Gas Allowance (complete question 2), or
Group Account Allowance (complete question 3), or
Bottled Gas Allowance (complete question 3).
4. Television Licence:
What is your television
licence number?
Who is your electricity
supplier?
2. Gas Allowance:
You must be registered, or a jointly registered consumer, that is your name must be on the bill,
before the allowance can be credited to your bill. Please contact your supplier if this is not the
case. Please provide a copy of your gas bill.
Allowance(s) you are applying forPart 2
Please tick if you wish to apply for:
Television Licence (complete question 4)
DO NOT LEAVE BLANK IF YOU ARE APPLYING FOR THE GAS ALLOWANCE
DO NOT LEAVE BLANK IF YOU ARE APPLYING FOR THE ELECTRICITY ALLOWANCE
Page 3
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45678123
Send this completed application form with copies of relevant bills to:
Household Benefits Section
Department of Social Protection
Social Welfare Services
College Road
Sligo
F91 T384
Telephone: (071) 915 7100
LoCall: 0818 200 400
If you are calling from outside of Ireland please call + 353 71 915 7100
10K 09-21 Edition: September 2021
Data Protection Statement
The Department of Social Protection administers Ireland’s social protection system. Customers are required
to provide personal data to determine eligibility for relevant payments and benefits. Personal data may be
exchanged with other government departments and agencies where provided for by law. Our data protection
policy is available at www.gov.ie/dsp/privacystatement or in a hard copy.
Explanations and terms used in this form are intended as a guide only and are not a legal interpretation.
Part 3 Your payment details
Page 4
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 details required below printed on statements from your financial institution.
Name 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 the name and address of the post office where you wish to collect your payment below.
