Disability Allowance Application Form
Part 1
Your own details (person who is disabled or ill)
DA 1
Social Welfare Services
Data Classification R
Signatur
e (no
t block let
ters)
Date:
D D M M Y Y Y Y
2
0
Declaration
10.Y
our telephone number:
11.Your email address:
Contact Details
9. Your address:
M O B I L E
L A N D L I N E
I declare that the information given by me on this form is truthful and complete. I understand that if any of the
information I provide is untrue or misleading or if I fail to disclose any relevant information, that I will be required
to repay any payment I receive from the Department and that I may be prosecuted. I undertake to immediately
advise the Department of any change in my circumstances which may affect my continued entitlement.
1. Your PPS No.:
3. Surname:
7. Your date of birth:
4. First name(s):
Mr. Mrs. Ms.
Other
2.
Title: (insert an ‘X’ or
specify)
6. Birth surname:
5. Y
our first name(s) as appears
on your birth certificate
:
8. Your
m
othe
r’s
b
irth
surna
m
e:
D D MM Y Y Y Y
Signatur
e of w
itness (no
t block let
ters)
Date:
D D M M Y Y Y Y
2
0
If you cannot sign your name, make a mark, such as an X and have it witnessed.
Page 1
21D40862
County Postcode
Warning: If you make a false statement or withhold information, you may be
prosecuted leading to a fine, a prison term or both.
1642642B
Application form for
Disability Allowance
Page 3/36
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Disability Allowance Application Form PDF
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