Application Form for Maternity Benefit
How to complete this application form.
• Please use this page as a guide to filling in this form.
• Please use black ball point pen.
• Please use BLOCK LETTERS and place an X in the relevant boxes.
• Please answer all questions that apply to you.
• You need a Personal Public Service Number (PPS No.) before you apply.
Employee or Self-Employed:
If you are an employee or self-employed fill in Parts 1, 2, 3, 5, 7 and 8 as they
apply to you. When form is completed, read Part 9 and sign declaration in Part 1.
Please note photocopies of this declaration are not acceptable.
To qualify for the maximum period of 26 weeks maternity leave, an employee
must take at least 2 weeks before the end of the week in which her baby is due.
Please only complete and stamp Part 6 after the 24
week of pregnancy.
Please only complete and stamp Part 4 after the 24
week of pregnancy.
It is acceptable to forecast your employee’s PRSI contributions for any period
after the 24
week of pregnancy up to the date she starts maternity leave.
If your employee has been working for you for less than 12 months before the
start of her maternity leave, please forward a copy of her P45 from her previous
If you need any help to complete this form, please contact Maternity Benefit
Section, your local Citizens Information Centre, your local Intreo Centre or your
local Social Welfare Office.
For more information, log on to www.welfare.ie.
Submit this form at least 6 weeks (12 weeks if self-employed) before you intend
to start maternity leave.
Please do not submit this form more than 16 weeks before the end of the week in
which your baby is due.
Application form for
Data Classification R
Social Welfare Services
Application Form for Maternity Benefit PDF
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