Social Welfare Services Office
Claim form for
Maternity Benefit
Complete this claim form as follows:
— if you are in Employment - Complete PARTS 1, 2 and 5 to 10
— your Employer must complete and stamp PART 3
— if you are Self-Employed - Complete PART 1 and PARTS 4 to 10
REMEMBER: Your Doctor MUST complete and stamp PART 11.
• Please use BLOCK LETTERS and place a tick ( ! ) in the boxes provided.
•
Please answer ALL questions, if some questions do not apply to you draw a line through the answer box.
•
Failure to answer questions could cause a delay in processing your claim.
PART 1
Please state:
1.
Your Full Name
‘Maiden Name’ is your name
before you married.
2.
Where do you live?
3.
Telephone Number if any
Your Own Details
Mrs.
Miss
Last Name
First Name(s)
Maiden Name (if any)
Address
Code
4.
Your Date of Birth
5.
Your RSI Number
(same as tax number)
6.
Your Old Social Insurance
Number if you have one
Ms.
Local Number
DAY
MTH
YR
LETTER(S)
FIGURES
This number was used prior to 1979 - if no number write ‘none’.
7.
Are you?
‘Cohabiting’ means you live
with a man as his wife and you
are not married to him.
8.
If you are Married when did
you get Married?
Married
Single
Separated
Cohabiting
Widowed
Divorced
DAY
MTH
YR
MB 10
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PART 2
Your Employment Details
‘Employed’ is where you work
for another person or company
and you get paid for this work.
9.
Are you employed at present?
YES
y
r
NO
If YES please state:
a
u
r
b
e
Employer’s Name
Who do you work for?
Address
What is your job?
Occupation
Is your employment full-time
or part-time?
FULL-TIME
F
:
PART-TIME
If PART-TIME state how much
you get paid
Gross Pay £
n
o
i
s
r
e
‘Gross pay’ is your pay BEFORE
any deductions are made
e.g tax, PRSI, union dues etc..
10. When do you intend to start
Maternity Leave?
11. If you are not in employment
when did you last work?
V
t
Who did you work for?
e
n
r
What was your job?
If YES please state how you
are related to him/her:
DAY
MTH
YR
DAY
MTH
YR
MTH
YR
Employer’s Name
Address
Occupation
12. When did you originally start
working?
13. Are you related to your
employer?
a week
DAY
YES
NO
Relationship:
If you are in Employment your EMPLOYER must complete PART 3 across
e
To be completed by your EMPLOYER
PART 3
REMEMBER: An employee MUST give at least 4 weeks notice of her intention to take Maternity Leave.
14. Please state your Employee’s
Name
Her Full Name
16. Please give details of
Employee’s PRSI record for
the 12 month period
immediately before her
Maternity Leave starts:
a
u
r
b
e
Number
Period of Employment
FROM
DAY
TO
MTH
y
r
LETTER(S)
FIGURES
15. Her RSI Number
(same as tax number)
YEAR
DAY
PRSI
of Weeks Class
MTH
YEAR
Class
If more than ONE Class of PRSI has been paid, please give details.
Period of Employment
F
:
FROM
DAY
TO
MTH
YEAR
n
o
i
s
r
e
17. Has Employee given notice of
her intention to take
Maternity Leave?
V
t
Number PRSI
of Weeks Class
YES
DAY
MTH
YEAR
Class
Class
Class
Class
NO
I/We certify that the above-named employee has given notice of her
intention to take Maternity Leave as follows:
If YES please complete across:
e
n
r
FROM
TO
DAY
MTH
YR
DAY
MTH
YR
Signed by or on behalf of EMPLOYER:
NAME:
Employer’s Official Stamp
(NOT block letters)
POSITION IN COMPANY/
ORGANISATION:
EMPLOYER’S REGISTERED NUMBER:
TELEPHONE
NUMBER:
Code
Local Number
DATE:
WARNING - EMPLOYERS PLEASE NOTE:
False or misleading statement made in order to obtain Maternity Benefit for another person can result in a fine of
up to £10,000 or Imprisonment for up to 3 years, or both.
e
PART 4
Details of Self-Employment - complete here if you
are or were self-employed
‘Self-employed’ is where you
work for yourself.
18. Are you or have you ever
been self-employed?
YES
a
u
r
b
e
If YES please state:
What is/Was your profession?
Occupation
When did you start
self-employment?
DAY
MTH
If you are no longer
self-employed when were
you last self-employed?
DAY
MTH
19. When do you intend to start
Maternity Leave?
F
:
DAY
MTH
n
o
i
s
r
e
20. What date do you intend to
return to self-employment
after your Maternity Leave?
21. Please give details of your
self-employment business as
follows:
y
r
NO
DAY
MTH
YR
YR
YR
YR
Business Name
Address of Business
V
t
e
n
r
22. Is your business a Limited
Company?
23. Are you a Sole Trader?
Business Registration Number
Business Telephone Number
Code
YES
Local Number
NO
• IF YES ATTACH A COPY OF YOUR P35 FOR THE RELEVANT
TAX YEAR(S).
YES
NO
• IF YES ATTACH A NOTICE OF ASSESSMENT OF TAX FOR THE
RELEVANT TAX YEAR(S) AND A COPY OF A RECEIPT OF
PAYMENT FROM THE REVENUE COMMISSIONERS.
Remember to send in ALL the Certificates/Documents with this claim.
Work Details in Another EU Country
PART 5
24. Have you ever been employed
in an EU country other than
Ireland?
YES
NO
y
r
If YES complete the following:
Country where
you worked
EMPLOYER’S
Name and Address
25. Have you been employed in
Ireland since you returned?
PART 6
Your Social Security
Number there
Dates you worked there?
FROM:
TO:
YES
NO
F
:
a
u
r
b
e
FÁS Courses/Other Claims Details
If you have claimed or you have been paid any social welfare payments, or if you have participated in a FÁS course
in the last 2 years, you may be entitled to credited contributions (credits) to help you qualify for Maternity Benefit.
e
n
o
i
s
r
e
26. Give details of FÁS courses
you have attended (if any):
27. Have you during the last 2 years
‘signed’ for Unemployment
Benefit/Assistance or for ‘credits’?
If YES please state:
Type of FÁS course
YES
Date you last signed/attended
V
t
Name of local Social Welfare
Office you attended
28. Are you being paid any pension,
benefit or assistance from the
Department of Social, Community
and Family Affairs (formerly the
Department of Social Welfare)?
e
n
r
If YES please state:
29. Are you getting any payment(s)
from a Health Board?
If YES please state:
FROM:
DAY
TO:
NO
MTH
YR
Local Social Welfare Office
Address
YES
NO
Type of Payment
Claim/Reference Number
Amount you get
£
YES
Type of Payment
Name of Health Centre
that pays you
a week
NO
e
Your Husband/Partner’s Details
PART 7
Your ‘partner’ is a man who is not
married to you but lives with you as
your husband.
Please state:
y
r
Mr.
30. Your Husband/Partner’s Full
Name
Last Name
a
u
r
b
e
First Name(s)
31. His RSI Number (same as tax
number)
32. Is your husband/partner in
employment?
YES
If YES please state your
husband/partner’s gross
weekly income:
F
:
V
t
— from the Department of
Social, Community and
Family Affairs (formerly the
Department of Social
Welfare)?
per week
If his Gross Weekly Income is under £105 per week please send in his
last 6 payslips as a higher rate of Maternity Benefit may be payable.
n
o
i
s
r
e
33. Is your husband/partner
getting a weekly payment:
e
n
r
NO
His Gross weekly income £
‘Gross Income’ is his pay
BEFORE any deductions are
made e.g tax, PRSI, union dues
etc..
or
LETTER(S)
FIGURES
YES
NO
YES
NO
Type of Payment
— from a Health Board?
Amount he gets £
If YES please state:
Claim/Reference Number
Name of Office that pays him
a week
e
Child Dependant Details
PART 8
If you qualify for Maternity Benefit you will be entitled to a rate of payment not less than the rate of Disability Benefit
which would be paid to you if you were absent from work through illness.
To enable us to calculate the correct rate of benefit, you must give details of your child dependants (that is, your
children under age 18).
34. Do you have a child or children
under age 18?
If YES please give details here:
YES
NO
Date of Birth
Child’s Full Name
PART 9
Your Maternity Benefit can be made:
*Type of Account: The account
used must be a Current or Deposit
Savings Account (NOT a mortgage
account).
YEAR
Payment Details
—
—
V
t
MTH
How is s/he Is this child
related
living
to you?
with you?
F
:
n
o
i
s
r
e
35. If you are getting Child
Benefit, what is your Child
Benefit Number?
e
n
r
DAY
y
r
a
u
r
b
e
Start with your eldest child
by Direct Payment to a Bank or Building Society Account*
or
by cheque direct to you at home.
Give details here if you want your payment made by Direct Payment:
into a Bank Account
into a Building Society Account.
Bank/Building Society Name
Bank/Building Society Address
Whose name is the Account in?
Type of Account
Account Number
Sort Code
Payment by Cheque direct to me at home.
PART 10
Declaration to be completed by YOU
I wish to claim Maternity Benefit.
I declare that the information I have given is true and complete to the best of my knowledge. I will tell the Department of Social,
Community and Family Affairs if there is any change in the details given.
y
r
YOUR Signature or Mark
DATE
(NOT block letters)
a
u
r
b
e
If the claimant is unable to sign, her mark should be made and witnessed. The witness should sign below:
SIGNATURE OF
WITNESS
DATE
(NOT block letters)
ADDRESS OF WITNESS
IMPORTANT: You should claim at least 6 weeks BEFORE you intend to start Maternity Leave.
WARNING: Penalty for false statement or withholding information: Fine or Imprisonment or both.
F
:
To be completed by your DOCTOR
PART 11
This section should be completed NOT earlier than 16 weeks before your baby is due.
n
o
i
s
r
e
To
(Name of Claimant)
my opinion you may expect to be confined on
Date of Examination
DAY
DOCTOR’S
SIGNATURE:
(NOT block letters)
ADDRESS
V
t
DAY
I certify that I have examined you and that in
MTH
(that is, expected date of delivery)
MTH
.
YR
YR
Doctor’s Official Stamp
This completed Claim Form should be sent to:
e
e
n
r
Maternity Benefit Section
Social Welfare Services Office
Government Buildings
Ballinalee Road
Longford.
If you have any problem filling in this form, please phone us at the
following telephone numbers or call to your local Social Welfare Office:
Telephone:
Longford
Dublin
(043) 45211
(01) 8748444
The Department of Social, Community and Family Affairs will treat all information and personal data which you
give as confidential. It will only be disclosed to other bodies in accordance with Social Welfare law and it will be
the Department’s responsibilities under the Data Protection Act and Freedom of Information Act.
40K10-99
Data Protection and Freedom of Information
Edition: Oct., 1999
INT: Mar 2000
If you are Self-Employed remember to send in ALL the Certificates/Documents with this claim.