VC 1 - Welfare.ie

Page 1. Part 1. Your own details. 1. Your PPS No: 3. Surname: 7. ... Please do not forward any payment with this application. • If a question does not apply to you, ...
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Application form for

Social Welfare Services

Voluntary Contributions

Data Classification R

• • • • •

VC 1

Please use BLOCK LETTERS. Please use BLACK INK and complete all questions. Please do not forward any payment with this application. If a question does not apply to you, please leave the answer area blank. Log on to www.welfare.ie for more information.

Part 1

Your own details

1. Your PPS No: 2. Title: (insert an ‘X’ or specify)

Mr.

Other

Mrs.

Ms.

M M

Y Y Y Y

3. Surname: 4. First name(s): 5. Your birth surname: 6. Your mother’s birth surname: 7. Your date of birth: D D

Contact Details 8. Your address:

LANDLINE

9. Your telephone number:

MOBILE 10.Your email address:

Declaration I declare that all the information I have given on this form is accurate. I will tell the Department when my circumstances change. Date: D D

2 0 M M

Y Y Y Y

Signature (not block letters)

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

Part 1 continued

Your own details

11.Are you?

Single

Cohabiting

Married

In a Civil Partnership

Separated

A surviving Civil Partner

Divorced

A former Civil Partner (you were in a Civil Partnership that has since been dissolved)

Widowed

12. If married, in a civil partnership or cohabitating, from what date?

D D

M M

Y Y Y Y

13. Your nationality:

Your employment details

Part 2

If you are or have been employed or self-employed please complete question 14 to 17. 14.Are you self-employed at present? If ‘Yes’, please state:

No

Yes

Your occupation: Dates of selfemployment:

From: To: D D

15.Are you employed at present? If ‘Yes’, please state:

M M

Y Y Y Y No

Yes

Your occupation: Your employers name: Dates of this employment:

From: To: D D M M Y Y Y Y Please attach your P45 if available

16.Have you a rental or lease income from farm, land, property or investment income? Yes No If ‘Yes’, please state: Amount:



,

.

a year

Part 2 continued

Your employment details

17.Please provide details of any previous employment in Ireland: Employer’s name, if applicable: Dates you worked there: From: To: D D

M M

Y Y Y Y

D D

M M

Y Y Y Y

D D

M M

Y Y Y Y

Employer’s name, if applicable: Dates you worked there: From: To: Employer’s name, if applicable: Dates you worked there: From: To: Note: A separate sheet of paper can be used for more details if needed. 18.Please state from what year you wish to pay voluntary contributions:

D D

M M

Y Y Y Y

19.Do you wish to pay voluntary contributions on an on-going basis? No

Yes

20.If you have ever lived or been employed outside the Republic of Ireland, please specify the details below. Country 1 Country: Dates you worked there: From: To: D D Your social insurance number while there:

M M

Y Y Y Y

Part 2 continued

Your employment details Country 2

Country: Dates you worked there: From: To: D D

M M

Y Y Y Y

Your social insurance number while there: Note: A separate sheet of paper can be used for more details if needed. 21.If you are getting or have applied for any payment(s) from this Department or from the Health Service Executive, please state: Name of payment: Claim or reference number: Date of first payment, if applicable:

D D

M M

Y Y Y Y

Homemakers Scheme Since 6 April 1994, if you spent time caring for dependent child(ren) under age 12 or for an ill or disabled person, on a full-time basis, we will ignore the resulting gap in your record when working out the yearly average of PRSI contributions for your State Pension (Contributory). For more information on Homemakers scheme, log on to www.welfare.ie, or contact: Homemakers McCarter's Road Ardarvan Buncrana Co Donegal LoCall: 1890 690 690 (from the Republic of Ireland only) or + 353 1 4715898 (from Northern Ireland or overseas)

Send this completed application form to: Client Eligibility Services Social Welfare Services Government Offices Cork Road Waterford LoCall:1890 690 690 (from the Republic of Ireland only) or + 353 1 4715898 (from Northern Ireland or overseas) Data Protection and Freedom of Information We, the Department of Social Protection, will treat all information and personal data you give as confidential. We will only disclose it to other people or bodies according to the law. Explanations and terms used in this form are intended as a guide only and are not a legal interpretation. 0K 06-12

Edition: June 2012