Disability Allowance Application Form
5534164D
Your own details (person who is disabled or ill)
Part 1 continued
Your work and claim details Part 2
If your work is considered to be of a rehabilitative nature, please attach medical evidence.
14.Do you live on an island
off the coast of Ireland?
Yes
No
If ‘Yes’, please state:
Type of work:
13.If you are married, in a civil partnership or cohabiting, from what date?
D D MM Y Y Y Y
12.A
re you?
Single
Married
Separated
Divorced
Widowed
Cohabiting
In a Civil Partnership
A surviving Civil Partner
A former Civil Partner
(you were in a Civil Partnership
that has since been dissolved)
Name of this island:
Employer’s name:
Employer’s address:
15.Are you employed at
present?
Yes
No
If ‘Yes’, please state:
Gross weekly
earnings:
Please attach 3 of your most recent payslips.
a week
€ , .
Page 2
EDEA48EE
Disability Allowance is a means tested payment. You are legally obliged to declare all your
means which include money in cash or in a financial institution, savings, shares, bonds,
funds, property (other than your own home), foreign pensions etc. Please include written
evidence such as statements and payslips with your application. Failure to do so could result
in a delay in processing your application.
You must also declare the means of your spouse, civil partner or cohabitant even if you are
not claiming an increase for a qualified adult.
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