Hse Medical Card And Gp Visit Card Application Form Page 7
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12Medical Card and GP Visit Card Form MC1 7
Part 3 ̶ Details of income ̶ continued
D. Savings and investments
Do you or your spouse or partner have investments in stocks, shares or savings
with banks or building societies or other financial institutions?
Yes
No
If ‘No’, go to Part E on this page.
If ‘Yes’, please complete the details below and remember to attach photocopies of the documents you need
to send us as evidence of your income from these sources, for example, statement(s) from financial
institution(s) showing the current balance on account(s).
Amount(s) invested
Name and address of financial institution
Type of savings or investments
or held in savings E
where invested or deposited
If you don’t have enough room to complete this section, please write additional details on a separate sheet
of paper and send it in with this form.
E. Property additional to the family home
Do you or your spouse or partner own any property or land other than the
house you live in, including land not personally used?
Yes
No
If ‘No’, go to Part 4 on next page.
If ‘Yes’, please complete the details below and send us evidence of any income from this source, for
example, tenancy agreement or bank statements. Also, if it applies, please send us evidence of any costs
associated with the land or property, for example, receipts or invoices.
Address
Details of land or property
Yearly income received
Yearly costs €
(for example, 3 bed semi, shop
(for example, from rental,
unit, farmland or other)
from lease or from other)
If you don’t have enough room to complete this section, please write additional details on a separate sheet
of paper and send it in with this form.
MC1 May 2015
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