Application Form for Fuel Allowance under the National Fuel Scheme
Part 1 continued Your own details
13.Are you getting a payment from this Department?
Yes
No
14.If ‘Yes’, please state name of payment:
19.If you have savings in a financial institution, please state:
20.If you own property, other than your home, please state:
Market value of
property:
Amount of savings:
16.If you are employed or self-employed, please state:
18.If you own stocks, shares or investments, please state:
Gross income:
a week
Their value:
17.If you have income from any source such as an occupational pension and including any
pension from another country, please state:
Gross income:
21.If this property is rented out, please state:
Rental income:
€
a week
€
a week
€
€
, .,
, .
, .
, .
22.If you have a business, please state:
Yearly profit:
€
, .,
12.Are you?
Single
Widowed Remarried
Married Cohabiting
Divorced
Separated
Your claim and income details Part 2
15.If you are getting a pension or allowance from another country, please state:
Name of country:
Claim or reference number:
Name of payment:
How long have you been
getting this payment?
months
€
, .,
€
, .,
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