Social Welfare Services Application form for HRC 1 ... · If ‘Yes’ to any of these 3 questions, please enclose your original permit and/or your original ... for example, documents/evidence

Application form for

Habitual Residence Condition

D D M M 2 0 Y Y

Thank you for your application for on

. However, we need more information to decide if you are habitually resident in the Republic of Ireland. Please answer the questions inthis form to help us decide this issue.

You need a Personal Public Service Number (PPS No.) before you apply.

How to complete this application form.

• Please tear off this page and use as a guide to filling in this form.

• Please answer all questions.

• Please use black ball point pen.

• Please use BLOCK LETTERS and place an X in the relevant boxes.

applicant:

Fill in all Parts. Incomplete forms will be returned and this may delay your application. When the form is completed, sign declaration in Part 1.

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.

Data Classification R

Social Welfare Services

HRC 1

Important

If you fail to provide relevant information or if you provide information which is untrue or misleading you will be required to repay any payment you received from the Department and you may be prosecuted. You must notify the Department of any change in your circumstances.

How to fill in first page of 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

Mr. Mrs. Ms. Other

Contact Details

X

M A R Y

K E L L Y

1. Your PPS No.:

3. Surname:

4. First name(s):

2. Title: (insert an ‘X’ orspecify)

6. Birth surname:

5. Your first name as itappears on your birthcertificate:

8. Your mother’s birthsurname:

2 8 0 2 1 9 7 0

D D M M Y Y Y Y7. Your date of birth:

L A N D L I N E

M O B I L E

O N E C H A R A C T E R P E R

B O X

10.Your telephone number:

11.Your email address:

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

9. Your address:

County D O N E G A L Postcode

Part 1 Your own details

1. Your PPS No.:

3. Surname:

7. Your date of birth:

4. First name(s):

2. Title: (insert an ‘X’ orspecify)

6. Birth surname:

5. Your first name as itappears on your birthcertificate:

D D M M Y Y Y Y

Contact Details

Application form for

Habitual Residence Condition

Mr. Mrs. Ms. Other

Data Classification R

Social Welfare Services

HRC 1

Signature (not block letters)

Date:

D D M M Y Y Y Y

2 0

Declaration

Warning: If you make a false statement or withhold information, you may beprosecuted leading to a fine, a prison term or both.

10.Your telephone number:

11.Your email address:

L A N D L I N E

M O B I L E

I declare that the information given by me on this form is truthful and complete. I understand that ifany 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 beprosecuted. I undertake to immediately advise the Department of any change in my circumstanceswhich may affect my continued entitlement.

8. Your mother’s birthsurname:

9. Your address:

County Postcode

Your own detailsPart 1 continued

16.What country were youborn in?

17.Your nationality?

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 Partnershipthat has since been dissolved)

13.If you are:Married or entered into a civil partnership, from what date? D D M M Y Y Y Y

Cohabiting, from what date?

D D M M Y Y Y Y

Separated, divorced or civil partnership dissolved,from what date? D D M M Y Y Y Y

A copy of your divorce or separation papers must be submittedwith your claim.

Yes No

If your spouse, civil partner or cohabitant died, what was their date of death?

D D M M Y Y Y Y

14.Would you like an interpreter service to help us process your application?

15.Do you have a current Garda National Immigration Bureau (GNIB) Card?

If ‘Yes’, please state:

Your GNIB Number:

Yes No


19.Please give details of each country, outside the Republic of Ireland, that you have lived in.

Country:

Dates:

Country 1

From:

To:D D M M Y Y Y Y

Residency outside the Republic of Ireland

Your social insurancenumber while there:

Did you have the necessary permission to reside in that country?

Yes No

If ‘No’, please outline the circumstances of your residency:

How did you support yourself while you lived in that country?

The European Economic Area (EEA) comprises the Member States of the European Uniontogether with Iceland, Norway and Liechtenstein.

18.If you are not an EEA national, do you hold a current: Irish Residence Permit?

Irish Employment Permit?

Student Visa?

If ‘Yes’ to any of these 3 questions, please enclose your original permit and/or your originalletter from the Department of Justice, which sets out the reasons that you have been grantedpermission to reside in the Republic of Ireland.

If ‘No’ to any of these 3 questions, have you applied for permit renewal?

Please give further details as to your residency and/or employment status, and enclose anyrelevant documentation (e.g. your original most recent permit and a copy of your renewalapplication).

Yes No

Yes No

Yes No

Yes No

Note: A separate sheet of paper can be used for more details if needed.


Residency outside the Republic of Ireland continued

Country:

Dates:

Country 2

From:

To:D D M M Y Y Y Y

Your social insurancenumber while there:Did you have the necessary permission to reside in that country?

Yes NoIf ‘No’, please outline the circumstances of your residency:


Country:

Dates:

Country 3

From:

To:D D M M Y Y Y Y

Your social insurancenumber while there:Did you have the necessary permission to reside in that country?

Yes NoIf ‘No’, please outline the circumstances of your residency:




Residency outside the Republic of Ireland continued

Yes No

20.Provide full details of your last address outside the Republic of Ireland.

Address:

Provide the most recent 6 months bank statements of all accounts held outside the Republicof Ireland as evidence.

21.Do you own or have you ever owned any kind of property/land/business/capital etc. outsideof the Republic of Ireland?


Address of the property:

Type of property (for example, house, apartment or lands):

Please provide evidence of your ownership of this property.

Did you live in theproperty?

Is the property rented?

Have you sold theproperty?

Yes No

Yes No

Yes No


If ‘Yes’, please provide a copy of a rental or tenancy agreement.

If ‘Yes’, please provide evidence of the completion of sale of this property.

22.Please give any further information that may assist your application.



Previous residency in the Republic of Ireland

23.Please give details of each period of time that you resided in the Republic of Ireland.

Dates:

1st period of residency

From:

To:D D M M Y Y Y Y

Did you have the necessary permission to reside in the Republic of Ireland at that time?

Yes No

If ‘No’, how did you support yourself during this period of residency in the Republic ofIreland?

Your address:

Dates:

2nd period of residency

From:

To:D D M M Y Y Y Y

Did you have the necessary permission to reside in the Republic of Ireland at that time?

Yes No

If ‘No’, how did you support yourself during this period of residency in the Republic ofIreland?

Your address:


Previous residency in the Republic of Ireland continued

24.Please give details of all your previous employments in the Republic of Ireland, starting withyour first employer.

Employer’s name:

Employer’s address:

Was your employment:

Did you have a written contract of employment?

Full-time Part-time

Yes No

From:

To:D D M M Y Y Y Y

Dates you worked there:

Number of hours worked aweek:

Employer 1

Employer’s name:


Was your employment:

Did you have a written contract of employment?

Full-time Part-time

Yes No

From:

To:D D M M Y Y Y Y

Dates you worked there:


Employer 2



Previous residency in the Republic of Ireland continued

25.Provide full details of your last address in the Republic of Ireland during your previous periodof residency.

Address:

Yes No

26. If you previously lived in the Republic of Ireland were you or your partner in receipt of asocial welfare payment or did someone claim for you as a dependent or student on a socialwelfare payment?

27.Why did you leave the Republic of Ireland?

28.Please provide any other details you feel may be relevant.

current residency in the Republic of Ireland

29.When did you come to live in the Republic of Ireland?

D D M M Y Y Y Y

30.Why did you decide to live in the Republic of Ireland?


Yes No

31.Have you lived in the Republic of Ireland continuously since the date you came to live here orreturned to live here?

If ‘Yes’, please provide proof of residency, for example, documents/evidence to show yourcontinuous residency in the Republic of Ireland such as a rental agreement and/or utility bills.

If ‘No’, state when you were absent from and to, and indicate why you left, for example, studyor holidays.

From:

To:D D M M Y Y Y Y

Dates you were absent:

Reason you left:

1st absence

current residency in the Republic of Ireland continued

From:

To:D D M M Y Y Y Y

Dates you were absent:

Reason you left:

2nd absence

Yes No

32.Are you currently working in the Republic of Ireland?

If ‘Yes’, please give details of employment.

Employer’s name:


Is your employment:

Do you have a written contract of employment?

Full-time Part-time

Yes No

D D M M Y Y Y Y

Date you started workingthere:




Yes No

33.Did you arrange or seek to find employment in the Republic of Ireland before coming to theRepublic of Ireland?

If ‘No’ please give details of how you have supported yourself since you came to the Republicof Ireland?

If ‘Yes’, please give details.

34.Were you self-employed? Yes No

If ‘Yes’, please give details including proof the self-employment was registered with theRevenue Commissioners.

Yes No

35.If you never worked in the Republic of Ireland, have you looked for work in the Republic ofIreland?

If ‘Yes’, please give details.


Yes No

36.Have you undertaken any training?

Please provide evidence of any training you have done or are currently doing.


37.How long do you plan to stay in the Republic of Ireland?

38.Please outline in full, the reason(s) for staying in the Republic of Ireland.

39.Please provide any other information that shows your connection to the Republic of Ireland.For example, if you belong to any professional bodies, community groups, social or sportsorganisations in the Republic of Ireland.

40.Please provide details of any substantial change in circumstances since your residency in theRepublic of Ireland.



41.Do you own or have you ever owned property, lands or businesses in the Republic of Ireland?


Address of the property:

Are you living in theproperty?

Is the property rented?

Have you sold theproperty?

Yes No

Yes No

Yes No

Yes No

Type of property (for example, house, apartment or lands):


Please provide evidence of your ownership of this property.

If ‘Yes’, please provide a copy of a rental or tenancy agreement.

If ‘Yes’, please provide evidence of the completion of sale of this property.

42.Do you have any bank accounts in other countries?

If ‘Yes’, please give details:

Yes No


Part 2

43.Their PPS No.:

45.Their surname:

46.Their first name(s):

44.Title: (insert an ‘X’ orspecify)

47.Their birth surname:

49.Their mother’s birthsurname:

51.Do they live in the Republic of Ireland with you?


Date their current stay inthe Republic of Irelandbegan: D D M M Y Y Y Y

If ‘No’, please state where they are and any plans you have made for them to join you:

50.Their nationality:

Mr. Mrs. Ms. Other

Yes No

Your spouse’s, civil partner’s or cohabitant’s details

52.Did your spouse, civil partner or cohabitant live in the Republic of Ireland previously?

If ‘Yes’, please outline when and the circumstances of their residency including employmentand/or self-employment details.

Yes No

53.Please give any other relevant information.


48.Their date of birth: D D M M Y Y Y Y

Yes No

54.Did they arrange work prior to coming to the Republic of Ireland?

If ‘Yes’, please give details:

55.Have they always worked since coming to the Republic of Ireland?

56.Are they employed at present in the Republic of Ireland?


Employer’s name:


D D M M Y Y Y Y

When employment started:

Is their employment:

Have they a written contract of employment?

How long is the job likely tolast?

D D M M Y Y Y Y

Yes No

Full-time Part-time

Yes No

Yes No

Yes No

Your spouse’s, civil partner’s or cohabitant’swork and claim details

Part 3

57.Are they currently getting a social welfare payment?

Name of payment:


If ‘No’, to question 57, have they previously got a social welfare payment?

Yes No

Name of payment:


59.Do all your children or other dependants live in the Republic of Ireland with you?

If ‘No’, please state where they are and any plans you have made for them to join you:

Yes No


58.Do you have children or other dependants?

If ‘Yes’, please state child or dependant’s:

Surname:

First name(s):

Child or dependant 1

Yes No

Details of your qualified child(ren)Part 4

D D M M Y Y Y YDate of birth:

Surname:

First name(s):

Child or dependant 2

D D M M Y Y Y YDate of birth:

Details of your qualified child(ren)Part 4 continued

60.Have you children in school in the Republic of Ireland?

Yes NoIf ‘Yes’, how manychild(ren)?

Please state:

D D M M Y Y Y Y

Surname:

First name:

Start date:

Name of school:

Address of school:

Child 1

D D M M Y Y Y Y

Date of birth:

D D M M Y Y Y Y

Surname:

First name:

Start date:

Name of school:

Address of school:

Child 2

D D M M Y Y Y Y

Date of birth:


D D M M Y Y Y Y

Surname:

First name:

Start date:

Name of school:

Address of school:

Child 3

D D M M Y Y Y Y

Date of birth:

D D M M Y Y Y Y

Surname:

First name:

Start date:

Name of school:

Address of school:

Child 4

D D M M Y Y Y Y

Date of birth:

D D M M Y Y Y Y

Surname:

First name:

Start date:

Name of school:

Address of school:

Child 5

D D M M Y Y Y Y

Date of birth:



Their PPS No.:

Their surname:

Their first name(s):


Their date of birth:

D D M M Y Y Y Y

Their address:

Their relationship to you:

Date they came to the Republic of Ireland:

D D M M Y Y Y Y

Person 1

Yes No

61.Does any of your close family (for example, parent, brother or sister) live in the Republic ofIreland?

Part 5 Details of other family members

Part 5 continued Details of other family members

Their PPS No.:

Their surname:



D D M M Y Y Y Y

Their address:



D D M M Y Y Y Y

Person 2

Their PPS No.:

Their surname:



D D M M Y Y Y Y

Their address:



D D M M Y Y Y Y

Person 3


Details of other family membersPart 5 continued


Their surname:



Their address:


Person 1

Yes No

62.Does any of your close family, for example parent, brother or sister, live outside the Republicof Ireland?

Their surname:


Their address:


Person 2

Their surname:


Their address:


Person 3

checklistPart 6

Your Residence Permit or renewal application

Your Irish Employment Permit

Your Work Permit

Your Student Visa

Your Garda National Immigration Bureau (GNIB) documents

Bank statements for the last 6 months for all bank accounts held outside the Republic ofIreland

Documentary proof of continuous residency in Ireland

Documentary proof of registration of self-employment with Revenue

If born, married or entered into a civil partnership or civil union outside the Republic of Ireland:

Your birth certificate

Your spouse’s, civil partner’s or cohabitant’s birth certificate

Your marriage certificate or civil partnership or civil union registration certificate

Your divorce, dissolution of civil partnership or separation documents

Only original certificates will be accepted

Have you enclosed the following?

Please remember to sign the Declaration in Part 1.

If you have any difficulty in filling in this form, please contact your local Citizens InformationCentre, your local Intreo Centre or your local Social Welfare Office.

0K 05-18 Edition: May 2018

Data Protection Statement

Personal data is required to determine eligibility for payments and services, administered forIreland’s social protection system. It may be shared with other GovernmentDepartments/Agencies where provided for by law. Data protection policy available atwww.welfare.ie/dataprotection or hard copy.

Explanations and terms used in this form are intended as a guide only and are not a legal interpretation.

Documents

Social Welfare Services Application form for HRC 1 ... · If ‘Yes’ to any of these 3 questions, please enclose your original permit and/or your original ... for example, documents/evidence