Disability Allowance Form
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36Social Welfare Services
DA 1
pplication form for
Data Classification R
Disability llowance
You need a Personal Public Service Number (PPS No.) before you apply.
How to complete this application form.
• Please use this page as a guide to filling in this form.
• Please use bl ck ball point pen.
• Please use BLOCK LETTERS and place an X in the relevant boxes.
• Please answer all questions that apply to you.
Please let us know your mobile phone number and we will text you right away
confirming that we received your application.
If you do not have a spouse, civil partner or cohabitant
:
Fill in Parts 1 to 6 and 10. You should sign Part 11 confirming that you allow your
doctor to give us the medical information needed to decide if you qualify for
Disability llowance. When form is completed, read Part 9 and sign declaration
in Part 1.
If you have a spouse, civil partner or cohabitant
:
Fill in Part 1 to 8 and 10. You should sign Part 11 confirming that you allow your
doctor to give us the medical information needed to decide if you qualify for
Disability llowance. When form is completed, read Part 9 and sign declaration
in Part 1.
Doctor
:
Please fill in the medical report at Part 12. Please make sure you sign and stamp
this part of the form.
If you need any help to complete this form, please contact your local Citizens
Information Centre, your local Intreo Centre or your local Social Welfare Office.
For more information, log on to
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