Form Cb 1 - Application Form For Child Benefit Page 3
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16Social Welfare Services
CB 1
pplication form for
Data Classification R
Child Benefit
Part 1
Your own details
1. Your PPS No.:
2. Title: (insert an ‘X’ or
Other
Mr.
Mrs.
Ms.
specify)
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:
County
Postcode
M O B I L E
10.Your telephone number:
L A N D L I N E
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.
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Parent category: Legal