Disability Allowance Application Form
6A60592E
Your work and claim details Part 2 continued
16.Are you getting a social security payment from another country?
Name of country:
Your claim or reference
number:
Amount:
Please attach the most recent payslip or letter from the Social Security Agency confirming the above
amount and also provide a 6 month bank statement for the account to which this payment is made.
Yes
No
If ‘Yes’, please state:
a week
€ , .
Who pays this pension:
Your claim or reference
number:
Amount:
Please attach the most recent payslip or letter from the people who pay you confirming the above
amount and also provide a 6 month bank statement for the account to which this payment is made.
Yes No
If ‘Yes’, please state:
a week
€ , .
18.Are you or have you been self-employed?
Type of work you do/did:
Net yearly earnings: a year
€ .,
This is the money you have made from self-employment after deducting operating expenses.
Yes
No
If ‘Yes’, please state:
Dates of self-
employment:
From:
To:
D D MM Y Y Y Y
17.Are you getting any other pension or allowance from the Republic of Ireland or from
another country?
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4FA7C0CD
19(a). Do you own, share in the ownership, work or rent a farm or land?
Size of farm or land:
acres
Net yearly income
or rent from farm
or land:
€ .,
‘Net yearly income’ is money you have made from the farm after
deducting operating expenses.
Yes No
If ‘Yes’, please state:
Herd or flock number:
19(b). If your farm or land is let, please state net yearly income from letting:
€ .,
Net yearly income:
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