Disability Allowance Application Form
362B1194
Your work and claim details Part 2 continued
22.Do you have savings or accounts in a bank, post office, building society, credit union or any
other financial institution in the Republic of Ireland or another country?
Yes
No
Page 5
Name of financial institution:
Current balance:
Financial Institution 1
Please attach an original statement for each account, showing transactions for the last 6
months.
If you have any other accounts you must give details of them to this Department on a
separate sheet of paper.
If ‘Yes’, please state:
€ .,
International Bank
Account Number (IBAN):
Name(s) of account holder(s):
Name 1:
Name 2 (if any):
Is this account a joint
account?
Yes
No
Bank Identifier Code (BIC):
Name of financial institution:
Current balance:
Financial Institution 2
€ .,
International Bank
Account Number (IBAN):
Name(s) of account holder(s):
Name 1:
Name 2 (if any):
Is this account a joint
account?
Yes
No
Bank Identifier Code (BIC):
D0AD6ADE
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