Job Seekers Benefits or Allowance Form
Single Married Widowed In a Civil Partnership
Separated Divorced Cohabiting
VERIFIED ( Y / N )
PART 1
PERSONAL DETAILS about you and your spouse, civil partner or cohabitant
DAY MONTH YEAR
FIGURES
LETTER
(S)
F
IGURES
LETTER(S)
VERIFIED ( Y / N )
DAY
MTH YR
DAY
MTH YR
Jobseeker’s Allowance or
Benefit
Application form for
UP 1
1. Please state:
• Personal Public Service Number
(PPS.no.)same as RSI/Tax Number
• First name(s)
• Surname
• Birth surname if different
• Address
(If you and your spouse, civil partner or
cohabitant are not living together give
both
Addresses)
• How long have you lived at this
address?
• Telephone/Mobile Number
If you enter your mobile number we may
text you in connection with your claim.
• Do you wish to avail of this service?
• Email address:
• Mother’s birth surname
• Distance from nearest Intreo Centre
or Social Welfare Local/Branch Office
• Nationality
• Your normal occupation
• Your last occupation
• Date of Birth
Attach your Birth Certificate
2. Are you?
• Date of marriage/civil partnership
If you are separated from your spouse,
civil partner or cohabitant please state:
• Amount of maintenance paid by you
• Date you last paid maintenance
3. Payment Details:
Give details of the Post Office at which
you wish to receive your payment.
APPLICANT Male/Female
A. POST OFFICE details
State NAME of POST OFFICE:
• Please answer ALL questions, except Part 2 in the case of JB claims, and place a tick ( ✓ ) in the boxes provided.
• Please use BLOCK LETTERS.
Intreo Centre/Social Welfare Local Office
ID Known
ID File Ph
ID Pass
ID DL
ID Other
S
cheme
C
omm
UP 20
Advised
about
Credits
PO Code
Occ
€
POST OFFICE details
per week/month
Male/Female
SPOUSE, CIVIL PARTNER
OR COHABITANT
VERIFIED ( Y / N )
DAY MONTH YEAR
YES NO YES NO
FOR
OFFICIAL
USE ONLY
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