Social Welfare Services Application form for BG 1 Data Classification R Bereavement Grant How to complete this application. • Please tear off this page and use as a guide to filling in this form. • Please use black ball point pen. • Please use BLOCK LETTERS and place an X in the relevant boxes. • Please answer all questions that apply to you. • You need a Personal Public Service Number (PPS No.) before you apply. Please note that Bereavement Grant is a contribution based payment. The grant cannot be paid if enough contributions have not been paid. When form is completed, read Part 5 and sign declaration in Part 1. If you need any help to complete this form, please contact your local Social Welfare Office or Citizens Information Centre. For more information, log on to www.welfare.ie. Important: You must apply within 12 months of the date of death, otherwise you may lose payment. You must enclose a death certificate/coroner interim cert and the funeral bill or receipt with this application. The funeral bill or receipt must be in your name or you must provide written permission from the person responsible for the bill, allowing you to claim Bereavement Grant. How to fill this form To help us in processing your application: • Print letters and numbers clearly. • Use one box for each character (letter or number). Please see example below. 1. Your PPS No.: 1 2 3 4 5 6 7 T 2. Title: (insert an ‘X’ or specify) Mr. 3. Surname: M U R P H Y 4. First name(s): M A U R E E N 5. Your first name as it appears on your birth certificate: M A R Y 6. Birth surname: M C D E R M O T T 7. Your mother’s birth surname: K E L L Y 8. Your date of birth: 2 8 0 2 1 9 7 0 D D M M Y Y Y Y Mrs. X Ms. Other Contact Details 9. Your address: 1 N E W O L D C O 10.Your telephone number: S T R E E T T O W N D O N E G A L O N E N U M B E R P E R B O X N U M B E R P E R B O X MOBILE O N E LANDLINE 11.Your email address: O N E C H A R A C T E R P E R B O X SAMPLE Social Welfare Services For Official Use Only Application form for BG 1 Bereavement Grant Part 1 Data Classification R Your own details 1. Your PPS No.: 2. Title: (insert an ‘X’ or specify) Mr. Mrs. Other Ms. 3. Surname: 4. First name(s): 5. Your first name as it appears on your birth certificate: 6. Birth surname: 7. Your mother’s birth surname: 8. Your date of birth: D D M M Y Y Y Y Contact Details 9. Your address: MOBILE 10.Your telephone number: LANDLINE 11.Your email address: Declaration I declare that the information given by me on this form is truthful and complete. I understand that if any of the information I provide is untrue or misleading or if I fail to disclose any relevant information, that I will be required to repay any payment I receive from the Department and that I may be prosecuted. I undertake to immediately advise the Department of any change in my circumstances which may affect my continued entitlement. 2 0 Date: D D M M Y Y Y Y Signature (not block letters) Warning: If you make a false statement or withhold information, you may be prosecuted leading to a fine, a prison term or both. Part 1 continued Your own details 12.How are you related to the deceased person? 13.Are you responsible for paying the funeral bill? No Yes If ‘Yes’, attach the funeral bill or receipt of payment in your own name. If ‘No’, do you have permission from the next-of-kin to apply for a Bereavement Grant? Yes No If ‘Yes’, attach the funeral bill or receipt of payment with a letter of authorisation from the person responsible for paying the funeral expenses. 14.Please give the address you last lived at, while insurably employed if different from Q9 on previous page: 15.Has there been or will there be a claim for payment in respect of the deceased, from any other country? Yes No If ‘Yes’, please give details: Part 2 Details of deceased person 16.Their PPS No.: 17.Their surname: 18.Their first name(s): 19.Their birth surname: 20.Their address: 21.Their date of birth: D D M M Y Y Y Y Part 2 continued Details of deceased person 22.What date did they die? D D M M Y Y Y Y Please attach the original death certificate if the death took place outside the Republic of Ireland. Please note that Bereavement Grant is a contribution based payment. The grant cannot be paid if enough contributions have not been paid. If the deceased person was a child or aged between 18 and 22 and in full-time education, please proceed to Part 4 of the form. 23.If they were married or in a civil partnership, from D D what date? M M Y Y Y Y 24.If they lived at another address before the one given at Q20, give details here: 25.If you have not applied for a Bereavement Grant within 12 months of the date of the person’s death, please give reason(s) why: 26.What was their old social insurance number? This number was used before 1979 27. What was their occupation? 28.Did the deceased person work as an employee in Ireland? Duration of employment: No Yes If ‘Yes’, please state: Employer’s name: From: To: D D M M Y Y Y Y 29.Was the deceased person getting any payment or pension or allowance from this Department or from the Health Service Executive? No Yes If ‘Yes’, please state: Name of payment: Their claim or reference number: Amount: € , . a week Part 2 continued Details of deceased person 30.Did the deceased person ever work and pay social insurance in another country? No Yes In some countries residence alone can provide cover for social insurance. If ‘Yes’, please state: Country where they worked or lived: Their address while there: Their social insurance number: Period(s) covered From: by social insurance: To: D D M M Y Y Y Y Note: A separate sheet of paper can be used for more details if needed. Part 3 31.Was the deceased person: Details of deceased person’s spouse, civil partner or cohabitant Single Cohabiting Married In a Civil Partnership Separated A surviving Civil Partner Divorced A former Civil Partner (you were in a Civil Partnership that has since been dissolved) Widowed If you have ticked one of the boxes at Q31 (excluding “Single”, “Divorced” or “A former civil partner”), please give the following details for the widowed spouse, civil partner or cohabitant: 32.Their PPS No.: 33.Their surname: 34.Their first name(s): 35.Their birth surname: 36.Their address (either a current address or their last address while in insurable employment): Part 3 continued Details of deceased person’s spouse, civil partner or cohabitant 37.Their date of birth: 38.Their date of death (if applicable): D D M M Y Y Y Y D D M M Y Y Y Y 39.Their old social insurance number, if any: This number was used prior to 1979 40.Their occupation: 41.Did the deceased person's spouse work as an employee in Ireland? Yes No If ‘Yes’, please state: Employer’s name: Duration of employment: From: To: D D M M Y Y Y Y 42.Did they ever work and pay social insurance in another country? Yes No In some countries residence alone can provide cover for social insurance. If ‘Yes’, please state: Country where they worked or lived: Their address while there: Their social insurance number: Period(s) covered From: by social insurance: To: D D M M Y Y Y Y Note: A separate sheet of paper can be used for more details if needed. Part 4 Your payment details Your Bereavement Grant may be paid to your current, deposit or savings account in a financial institution. Please note that the account must remain open until payment (if awarded) is made. Financial Institution You will find the following details printed on statements from your financial institution. Name of financial institution: Sort code: Account number: Bank Identifier Code (BIC): International Bank Account Number (IBAN): Name(s) of account holder(s): Name 1: Name 2 (if any): Part 5 checklist Have you enclosed the following? — Remember in all cases to send a death certificate / coroner's interim certificate and the funeral bill in your name, with your application. — Please get a letter from the school or college if your application is for a child aged between 18 and 22 who was in full-time education. Please remember to sign the Declaration in Part 1. If you have any difficulty in filling in this form, please contact your local Social Welfare Office or Citizens Information Centre. Send this completed application form to: Bereavement Grant Section Social Welfare Services College Road Sligo LoCall: 1890 500 000 (from the Republic of Ireland only) Telephone: 071 9157100 (from the Republic of Ireland only) or + 353 71 9157100 (from Northern Ireland or overseas) Note: The rates charged for using 1890 (LoCall) numbers may vary among different service providers. Data Protection and Freedom of Information We, the Department of Social Protection, will treat all information and personal data you give as confidential. We will only disclose it to other people or bodies according to the law. Explanations and terms used in this form are intended as a guide only and are not a legal interpretation. 75K 04-13 Edition: April 2013