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Coimisiún na Scrúdaithe Stáit

State Examinations Commission

Corr na Madadh, Baile Átha Luain, Co. na hIarmhí

Cornamaddy, Athlone, Co. Westmeath.

Telephone: +353-90-644 2877/2805/2802. Fax: +353-90-644 2807

Web:

E-mail:

financial@examinations.ie

SEC_MC1 – UNIVERSAL SOCIAL CHARGE – REDUCED RATE APPLICATION FORM

Please read the leaflet Financial Information for Examinations Contract Staff (FS_03_2011) prior to completing

this form. Complete the form in block capitals with the exception of the signature field. Complete Section A and

either Section B or Section C. The SEC reserves the right to verify the information submitted.

SECTION A. PERSONAL DETAILS

First Name: ________________________________

Surname: ___________________________________

PPSN

Address: ____________________________________________________________________________________

_____________________________________________________________________________________

Mobile Number: _______________________

Email: _____________________________________________

SECTION B. Entitlement to reduced rate application due to Medical Card

I declare that I am the holder a full medical card, which entitles me to a reduction in the higher rate of USC. The

details of the card, a photocopy of which is attached, are as follows;

Medical Card Number:

Issued by:

______________________________________________________________________

Valid from: __ / __ /____ Valid to: __ / __ / ____

Signature: ______________________________________________

Date:

__ / __ / ____

SECTION C. Entitlement to reduced rate application due to age

I declare that I am 70 years of age or over, or will turn 70 in the current calendar year, which entitles me to a reduction

in the higher rate of USC. My date of birth as per my birth certificate, a photocopy of which is attached, is as follows;

Date of Birth:

_ _ of _______________________, _ _ _ _

Signature: ______________________________________________

Date:

__ / __ / ____

Notes

•

Persons who are the holders of a

full

medical card or are 70 years or over are entitled to a reduced rate

application of the USC.

•

Persons who are the holders of the Health Amendment Act Card are entitled to the same exemption rights

as a holder of a full medical card.

•

UK and Northern Ireland Medical Cards are only applicable where they are accompanied by certification

that the recipient is entitled to full exemption from prescription charges also.

•

GP Visit Cards do not qualify the holder for the reduced rate application of the USC.

•

The reduction in rates will only be applied if the completed form is accompanied by a photocopy of the

valid medical card or birth certificate, which ever is applicable.

===========================================================================

The completed form and the copy of the medical card should be returned to the Finance Section (USC

Queries), State Examinations Commission at the address shown above.

Sec_mc1 Universal Social Charge Reduced Rate Application Form - State Examinations Commission

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