Disability Allowance Application Form
C59FE75D
Habitual Residence condition
Part 3
Yes No
29.What country were you
born in?
30.What is your nationality?
32.Have you lived outside the Republic of Ireland for any period longer than three months
within the last five years?
31.When did you come to
live in the Republic of
Ireland?
D D MM Y Y Y Y
If ‘Yes’,
please give details of where you lived in the space provided
.
Country:
Country 1
From:
To:
D D MM Y Y Y Y
Why you lived there:
Country:
Country 2
From:
To:
D D MM Y Y Y Y
Why you lived there:
For official use only
HRC not satisfiedHRC satisfied HRC1 issued
Page 8
07399BFA
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