Social Security: cb1

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Application form for

Child Benefit CB1

Social Welfare Services Office

• Please read information booklet SW 42 before you complete this form.

• Please use BLOCK LETTERS and place a tick () in the relevant boxes.

• Please answer all questions fully. If you fail to do so your application may be delayed.

Complete and return this application form within 6 months of the month in which:

• the child was born, or

• the child became a member of your family, or

• you or your family came to live in the Republic of Ireland.

Otherwise, you could lose out on benefit.If you are applying later than 6 months after any of the above events and you wish to apply for

arrears, you must give reason(s) for the late application in Part 8 and attach written evidence.

• Child Benefit is normally paid to the mother or step-mother, so she must complete and signthe declaration in Part 9. Sometimes Child Benefit is paid to other people. See information

booklet SW 42 available from your local Social Welfare Office or at your local post office.

Note: Child Benefit is not paid for the month in which the child is born.

Your own detailsPart 1

Figures Letter(s)1. What is your Personal PublicService Number (PPS No.)?

First name

6. Where do you live?

Mr. Mrs. Ms. Other

Yes No2. Have you claimed ChildBenefit in this countrybefore?

Please state:

3. What is your full name?

4. What is your birth surname

(your surname when youwere born), if different?

5. What is your mother’s birthsurname (her surnamewhen she was born)?

Last name

8. What is your date of birth? Day Month Year

Please specify.

Address

7. What is your telephone

number?Landline Mobile

9. Are you....? Married Single Separated

Cohabiting Widowed Divorced



Habitual residence is a condition that you must satisfy to qualify for Child Benefit. Seeinformation booklet SW108 for more information about habitual residence.

10. In what country were youborn?

11. What is your nationality?

12. Have you lived in theCommon Travel Area all of your life?

Yes

No

If ‘Yes’, please complete question 17 and 18

If ‘No’, please complete all remaining questions.

Your payment detailsPart 2

Child Benefit can be paid by direct payment into an account in a financial institution or an An PostChildcare Savings Account or by a payment book at a post office. See SW42 for details and choose theoption that suits you best.

Name of financial institution:

Address of financial institution:

Sort code ( you can get this fromyour branch):

Account number (8 digits only):

Name on the account:

Habitual Residence ConditionPart 3

If you are not an EU or EEA national, please attach your current Certificate of Registration (GNIB card)

Note:

The Common Travel Area is Ireland, Great Britain, the Isle of Man and the Channel Islands.

You can spend brief periods on short holidays, studying or travelling outside the CommonTravel Area and still be habitually resident here.

Direct to your account in a financial institution

Post office payment

Paid into an An Post Childcare Savings Account

Account number (8 digits only):

You can get an application form for this account from your local post office.

Payment book at a post officeName of post office:

Address of post office:



Habitual Residence ConditionPart 3 continued

Day Month Year

Yes No

Yes No

14. When did you come toIreland?Have you lived continuouslyin Ireland since the day youarrived?

15. Does any of your closefamily, for example parent,

brother, sister or child, live inIreland?

16. Have you ever applied for

refugee status?

(a) Are you waiting for adecision on anapplication for refugeestatus?

(b) Have you been grantedrefugee status or leave toremain in the State onother grounds?

If ‘Yes’, please give their details here:

Name Address Date of birth Relationship to you Date they came

17. Where have you lived in theCommon Travel Area?

Yes No

If ‘Yes’, please answer questions 16 (a)

and 16 (b) and provide copies of allrelevant documents from the Dept of

Justice Equality and Law Reform.

Yes No

Ireland

Isle of Man

Great Britain

Channel Islands

Last address Previous address in home country

From FromTo To

If you are a non-EU or non-EEA national or an asylum seeker, include current documents - such asa Cert of Residence or a Refugee Application Card - giving details of you and your family’sresidency status in Ireland. If you are an unemployed EU or EEA national or a non-EU or non EEAnational, please attach a completed and signed HRC1 form, which you can get from your localSocial Welfare Office.

18. Have you lived at the sameaddress for the last 2 years?If ‘No’, please give details of previous address in home country.

Yes No

Yes

No If ‘No’, please give details about each countryoutside the Common Travel Area where you havelived and complete all remaining questions.

13. Have you lived in theCommon Travel Area for thelast 2 years?

Country From To Why you lived there

If ‘Yes’, please complete question 17 and 18

Yes No



Your spouse’s or partner’s detailsPart 4

Day Month Year

First name19. What is your spouse’s or

partner’s full name?

20. What is your spouse’s or

partner’s birth surname?

Last name

21. Where do they live?

22. What is their date of birth?

23. What is their PPS No.?Figures Letter(s)

Employment and social welfare detailsPlease answer each question. Do not leave any blank.

Part 5

24. What is their nationality?

25. Are you...(a) employed or self employed?

(c) getting any other social

welfare benefit or pension?If ‘Yes’, please state:

Country that pays you:

(b) getting Child Benefit

If ‘Yes’, please state:

Reference number:

Last date of payment: Day Month Year

Address

Please attach a Certificate of Registration if your spouse or partner is a non-EU or non-EEA national.

Yes No

Yes No

If employed, please attach a letter from your employer, stating the date you started working, youremployer’s registered number and the class of social insurance paid.

Country of payment:

Name of benefit or pension:

Has payment stopped?

Your social insurance numbere.g. national insurance orPESEL number etc.:

Name of country where youwork:

Name of country in whichyou pay social insurance:

Name of employer:

Date you started yourcurrent employment:

Reference number:

Please state:

Yes No

If Polish national, pleasestate your NIP number:



27. If you have recently movedto Ireland when did you andyour family move to Ireland?

You

Day Month YearYour spouseor partner

Your spouse’s or partner’s employment andsocial welfare detailsPart 6

26. Is your spouse or partner...(a) employed or self employed?

(c) getting any other social

welfare benefit or pension?If ‘Yes’, please state:

Country that pays them:

Yes No

Yes No

Part 7 Details of qualified child(ren)

28. Please give details here of child(ren) you wish to claim for. If any child is adopted, fostered or

not your own, give details in the table below.

Please attach the original Birth Certificate for each child you are claiming for. We do notaccept photocopies. If you cannot get a Birth Certificate immediately, you should attach anote with your application stating that you will send the certificate(s) as soon as possible.

Child's full name

(including surname)Date of

birth

How is the

child related

to you?

Is this child

living with you

in Ireland?

Date they

came to live

with you

Day Month Year

(b) getting Child Benefit?If ‘Yes’, please state:

Yes No

Reference number:

Last date of payment:

Country of payment:

Day Month Year

Male or

Female

If No,

country they

live in

Name of benefit or pension:

Yourchildren Day Month Year

If employed, please attach a letter from their employer, stating the date they started working, theiremployer’s registered employer number and the class of social insurance paid.

Their social insurance numbere.g. national insurance orPESEL number etc.:

If Polish national, pleasestate their NIP number:

Name of country where theywork:

Name of country in which

they pay social insurance:

Please state:

Has payment stopped?

Reference number

Date they started theircurrent employment:

Name of their employer:



Part 7 continued Details of qualified child(ren)

29.How many children nowlive with you?

under 16 over 16

If any children are not living

with you, please state name of

the parent or guardian with

whom the child(ren) live.

First name

Last name

Adopted

Fostered

Not your own children

Yes No

Yes No

Yes No

If ‘Yes’, please state:

32.Are any of the childrennow living with you...?

Last name

First name(s)

Name of social worker:

Address of social worker:

Telephone number: (if known)

Address

If you want to claim for any children aged 16, 17 or 18 you should complete this form andform CB2, which you can get from your post office or local Social Welfare Office.

For each child of school going age living in Ireland, please attach a letter from their schoolor college to confirm the date they started attending.

For each child not of school going age living in Ireland, please attach a letter from yourdoctor or the Gardaí to confirm that the child is normally living in Ireland.

Late application detailsPart 8

If you have not applied within 6months, please give reason(s)why:Attach evidence in support of your reason(s) for claiming late if available.

Reason(s) for claiming late

I am applying for Child Benefit for the child(ren) outlined in Part 7.

I declare that the details on this form are true and correct and agree to inform Child Benefit Section if anyof the events listed in Part 11 occur.

I authorise the Department of Social and Family Affairs to get information from other agencies and makeany enquires about me that it needs to process this application.

Your signature Date

Warning: If you make a false statement or withhold information you may face a fine or prison term orboth. You will also have to refund any benefit the Department has overpaid you.

DeclarationPart 9

Landline Mobile

Address

30.What is their relationship tothe child/ren?

31.What is their social insurancenumber? e.g. national insurance,PESEL, NIP number etc.:



Part 10 Checklist of documents with your application

To avoid delay, please send all the certificates and documents that are needed with this form. If you

cannot send in one right away, please enclose a note stating that the certificate or document will

follow later.

If sending certificates or documents at a later date, please remember to state your full name, address

and your PPS Number.

Please ensure you have enclosed thefollowing certificates or documents withyour application (if applicable)

— Original Birth Certificate for each childyou wish to claim for

Yes No

— Current Certificate of Registration(GNIB card) for all non-EU and non-EEAnationals

Yes No

— Letter from school or college for each

child of school going age living inIreland confirming the date your childstarted attending

Yes No

— Letter from your doctor or the Gardaíconfirming residency of each child notof school going age living in Ireland

Yes No

— Letter from you and your spouse's orpartner’s employer with employer’sregistered number, the class of socialinsurance paid and start date of employment

Yes No

— Completed and signed HRC1 form forunemployed EU and EEA nationals andall non-EU and non-EEA nationals

Yes No

— Completed CB2 form for children aged16, 17 or 18

We normally accept only original documents and certificates. However, you may include‘verified copies’ of Birth Certificates and Certificates of Registration. These copies areoriginal documents that have been photocopied, stamped and signed by an official at anylocal Social Welfare Office or Garda station.

If you do not include a document or certificate needed with this form, your application maybe delayed.

If sending in a translation of a birth certificate, please attach the original birth certificate or a‘verified’ copy.

If you are applying for a child for whom Child Benefit is already being paid, you will not needto supply a birth certificate.

Yes No

— Relevant documents from the Dept of Justice, Equality and Law Reform if youhave applied for refugee status

Yes No

— Letter stating PESEL numbers for allfamily members (if Polish National)

Yes No

If you are sending in certificatesor documents later, give detailshere:

Important: If you are sending in certificates or documents later, remember to include your fullname, present address and your PPS number with them.



Events that may affect your Child Benefit.Part 11

You must notify Child Benefit Section in writing if any of these events occur.

• You change address

• You change post office

• You change bank or building society or An Post Childcare Account or account name

• A child aged 16, 17 or 18 finishes education or changes or leaves school or college

• There is a death of a child for whom benefit is being paid

• You or your child are imprisoned or admitted to a home or detention centre

• A child is no longer living with you or in your care

• A child is abandoned, deserted or removed from your custody

• You or your child leave the State

• You wish to nominate another person to receive benefit for you

• You marry or remarry

• You or your spouse or partner starts work in another country

• The person receiving child benefit dies

• You give birth to, adopt or foster further children• Your family come to live in the Republic of Ireland

Deciding Officer’s signature: Date

I award payment of Child Benefit/disallow payment of Child Benefit to the child(ren) named in Part 7with effect from: Month Year

Child Benefit Section

Social Welfare Services Office

St. Oliver Plunkett Road

Letterkenny

Co. Donegal

You can contact the Child Benefit Section by telephoning LoCall 1890 400 400.

Please send the completed application form to:

Department use only

HRC satisfied HRC not satisfied HRC1 issued

Explanations and terms used in this form are intended as a guide only and do not purport to be alegal interpretation.

100K 03-07 Edition: March 2007

Data Protection and Freedom of Information

We, the Department of Social and Family Affairs will treat all information and personal datawhich you give as confidential. We will only disclose it to other people or bodies in accordancewith law. We are responsible for your information under the Data Protection Act and Freedom

of Information Act.

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