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 gettin