Social Welfare Services

SPC 1
Application form for Data Classification R

State Pension (Contributory)

You need a Personal Public Service Number (PPS No.) before you apply.

How to complete this application form.
• Please tear off this page and use as a guide to filling in this form.

• Please answer all questions. Incomplete forms will be returned and this may
delay your application.

• Please use BLACK ball point pen.

• Please use BLOCK LETTERS and place an X in the relevant boxes.

If you do not have a spouse, civil partner or cohabitant:

Fill in Parts 1 to 6 as they apply to you. When form is completed, read Part 10
and sign declaration in Part 1.
If you have a spouse, civil partner or cohabitant:
Fill in Parts 1 to 7 as they apply to you. You must complete Part 8 fully if you
wish to claim an increase for your spouse, civil partner or cohabitant. Please note
that this increase is based on a means assessment. If claiming this increase for
your spouse, civil partner or cohabitant, you are legally obliged to declare all of
their income (including foreign pensions), savings and property (other than your
own home). Part 9 must be filled in and signed by your spouse, civil partner or
cohabitant. When form is completed, read Part 10 and sign declaration in Part 1.
If you have lived or worked in another country:
We will apply for a pension on your behalf to those countries covered by EU
Regulations or Bilateral Agreements.
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 www.gov.ie/dsp.
Important:
You should apply 3 months before reaching pension age. If you do not claim
within 6 months of becoming eligible, you could lose some payment.
 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 Number: 1 2 3 4 5 6 7 T
2. Title: (insert an X or Mr. Mrs. X Ms. Other
specify)
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 M A R Y
appears on your birth
certificate:
6. Birth surname: M C D E R M O T T
7 . Your mother’s birth K E L L Y
surname:
8. Your date of birth: 2 8 0 2 1 9 7 0
D D M M Y Y Y Y

Contact Details
9. Your address: 1 N E W S T R E E T
O L D T O W N
D O N E G A L T O W N
County D O N E G A L Postcode

10.Your telephone number: O N E N U M B E R P E R B O X

MOBILE
O N E N U M B E R P E R B O X
LANDLINE
11.Your email address: O N E C H A R A C T E R P E R

SAMPLE
B O X
 Social Welfare Services
Application form for SPC 1
Data Classification R

State Pension (Contributory)

Part 1 Your own details
1. Your PPS Number:
2. Title: (insert an X or Mr. Mrs. Ms. Other
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

10. Your telephone number: MOBILE

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.
4558149477
Date: 2 0
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.
Page 1

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Part 1 continued Your own details
12. Are you? Single Cohabiting
Married In a Civil Partnership
Separated A surviving Civil Partner
Divorced A former Civil Partner

Widowed (you were in a Civil Partnership

that has since been dissolved)
13. If you are married, in a civil partnership or cohabiting, please state from what date:

D D M M Y Y Y Y
14. Your country of birth:

15. Are you? Employed Retired Other

If Other, please specify:

Part 2 Your work and claim details

Your work details
16. Did you work in Ireland before 1979?
Yes No
If Yes, state your Social Insurance number or addresses you lived at during this time:
Your Social Insurance
number:
Address:

Address:

Address:
9893581979

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Part 2 continued Your work and claim details
17. If you are or were a teacher, civil servant or in the Army, please state:
Name of department/
school:

Address of department/
school:

School roll number, if

applicable:
Army number, if
applicable:
Dates you From:
worked there:
To:
D D M M Y Y Y Y
Pension payroll number:

18. Please give details of all your employments in Ireland:

Employer 1
Employer’s name:

Employer’s address:

Job title:
Dates you From:
worked there:
To:
D D M M Y Y Y Y

2571062463

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Part 2 continued Your work and claim details
Employer 2
Employer’s name:

Employer’s address:

Job title:
Dates you From:
worked there:
To:
D D M M Y Y Y Y
Note: A separate sheet of paper can be used for details of any additional employments that you had.
19. If you are or have been self-employed in the Republic of Ireland, please state:
Dates of self- From:
employment:
To:
D D M M Y Y Y Y
20. If you ever lived or worked outside the Republic of Ireland, please state:
Country 1
Country:

Employer’s name:
Your address while living/
working there:

Your social insurance

number while there:
Dates you From:
worked there:
To:
D D M M Y Y Y Y
Type of work:
2552291714

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Part 2 continued Your work and claim details
Country 2
Country:

Employer’s name:
Your address while living/
working there:

Your social insurance

number while there:
Dates you From:
worked there:
To:
D D M M Y Y Y Y
Type of work:

Country 3
Country:

Employer’s name:
Your address while living/
working there:

Your social insurance

number while there:
Dates you From:
worked there:
To:
D D M M Y Y Y Y
Type of work:
Note: A separate sheet of paper can be used for more details if needed.

8045232385

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Part 2 continued Your work and claim details

Your claim details

21. If you are getting a social security payment from another country, please state:
Name of country:
Your claim or reference
number:
Amount: € , . a week
22. Is your spouse, civil partner or cohabitant getting paid for you on their pension, benefit or
allowance, from Ireland or any other country?
Yes No
If Yes, please state:
Their claim or reference
number:

Part 3 Your payment details

You can get your payment at a post office of your choice or direct to your current, deposit or savings
account in a financial institution. An account must be in your name or jointly held by you. Please
complete one option below.

Financial Institution
You will find the following details printed on statements from your
financial institution.
Name of financial institution:

Bank Identifier Code (BIC):

International Bank Account
Number (IBAN):

Name(s) of account holder(s):

Name 1:

Name 2 (if any):

Post Office
Please enter below the name and address of the post office where you wish to collect your
payment.
Post office name and address:
8151648575

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Part 4 Details of your children
23.How many children who normally live with you do you wish to claim for:
under age 18

age 18 - 22 in full-time education

24.Please state children’s:
PPS Number:

PPS Number:

PPS Number:
Note: A separate sheet of paper can be used for more details if needed.

Part 5 Homemaker’s details

25. Since 6 April 1994, if you spent time caring for dependent children under age 12 or for an ill or
disabled person, on a full-time basis, please state the person’s / child’s:

PPS Number:

Surname:

First name(s):
Dates you were From:
caring this
person/child: To:
D D M M Y Y Y Y

2462140638

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Part 6 Other payments

Living Alone Increase

You may get a Living Alone Increase if you are getting a State Pension (Contributory) and live
alone or mainly alone. For more information, log on to www.gov.ie/dsp.
26. Do you wish to claim a Living Alone Increase?
Yes No
If Yes, please state date you started living alone or mainly alone:

D D M M Y Y Y Y

Household Benefits Package

You may qualify for the Household Benefits Package, which is made up of 2 allowances:
• Electricity or Gas Allowance
• Free Television Licence
For more information on extra benefits available to pensioners, log on to www.gov.ie/dsp .

Fuel Allowance
This allowance is subject to a means test of all the people living in your household (including
yourself). Only one person in a household can get this allowance.
27. Do you wish to apply for a Fuel Allowance?
Yes No
If No, please go to Part 7.
If Yes, please complete fully the remainder of this section. Do not leave any question blank. If no
income, please enter 0 in each of the amount boxes.
28. Your details:
Gross weekly income: € , . a week
Please provide documentary evidence from all sources of income.
Total savings/
investments: € , .
Please provide documentary evidence of all of these savings and investments.
Value of property:
(other than family home) € , , .
Please provide documentary evidence of all other properties you
have including address and valuation.
Rent from all property:
(other than family home) € , . a week
Please provide documentary evidence of all rents from other property.
3828253810
Profit from business: € , , . a year
Please provide documentary evidence such as the last available
copy of accounts.

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Part 6 continued Other payments
You must also complete Q.29 in respect of ALL the people living with you. If they have no
income please put a 0 in the amount boxes.

29. The following people live with me:

Person 1 living with me
Name:

PPS Number:

Gross weekly income: € , . a week

Total savings/
investments/property € , .
value: (not family home)
Profit from business: € , . a year

Person 2 living with me

Name:

PPS Number:

Gross weekly income: € , . a week

Total savings/
investments/property € , .
value: (not family home)
Profit from business: € , . a year

Person 3 living with me

Name:

PPS Number:

Gross weekly income: € , . a week

Total savings/
investments/property € , .
value: (not family home)
Profit from business: € , . a year

Note: If more than three people live with you, a separate sheet of paper can be used.
You may be asked to supply documentary evidence of all income.
5446386107

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 Your spouse’s, civil partner’s or cohabitant’s
Part 7
details
30. Their PPS Number:
31. Title: (insert an X or Mr. Mrs. Ms. Other
specify)
32. Their surname:

33. Their first name(s):

34. Their birth surname:

35. Their date of birth:

D D M M Y Y Y Y
36. Their mother’s birth
surname:
37. Their address:
Only answer this question
if you are married or in a
civil partnership and do
not live together.

Your spouse’s, civil partner’s or

Part 8
cohabitant’s work and claim details
38. Do you wish to claim an increase for your spouse, civil partner or cohabitant? (You must select
Yes or No).
Yes No
If No, please go to Part 10.
If Yes, please complete fully the remainder of this section. If they have no income, please put a 0
in each of the amount boxes.
The increase for a qualified adult is a means tested payment. The means of your spouse, civil
partner or cohabitant will be assessed.
Please supply documentary evidence (such as bank statements) for the last 6 months for all
savings, investments and income.

39. If they are getting any other pension (private or occupational) from another country, please state:

Type of pension:

Who pays this pension:

Their claim or reference
number:
Amount:
3179140184
€ , . a week

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 Your spouse’s, civil partner’s or
Part 8 continued
cohabitant’s work and claim details
40. If they are employed at present, please state:
Their employer’s name:

Their employer’s address:

Type of work:

Gross income: € , . year to date

Please attach 4 of their most recent payslips.
Number of weeks worked: year to date
41. If they are currently self-employed, please state:
Type of work they do/did:
Date self-employment
started:
D D M M Y Y Y Y
Net weekly earnings: € , . a week
This is the money they have made from self-employment after deducting operating expenses.
Please provide documentary evidence such as the last available copy of accounts.
42. If they have savings or accounts in a bank, post office, building society, credit union or any
other financial institution in the Republic of Ireland or another country, please state:
Financial Institution 1
Name of financial institution:

Bank Identifier Code (BIC):

International Bank Account
Number (IBAN):

Current balance: € , .
Is this account a joint account? Yes No
Name(s) of account holder(s):
Name 1:

Name
069517288
(if48any):

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 Your spouse’s, civil partner’s or
Part 8 continued
cohabitant’s work and claim details
Financial Institution 2
Name of financial institution:

Bank Identifier Code (BIC):

International Bank Account
Number (IBAN):

Current balance: € , .
Is this account a joint account? Yes No
Name(s) of account holder(s):
Name 1:

Name 2 (if any):

Financial Institution 3
Name of financial institution:

Bank Identifier Code (BIC):

International Bank Account
Number (IBAN):

Current balance: € , .
Is this account a joint account? Yes No
Name(s) of account holder(s):
Name 1:

Name 2 (if any):

Financial Institution 4
Name of financial institution:

Bank Identifier Code (BIC):

International Bank Account
Number (IBAN):

Current balance: € , .
Is this account a joint account? Yes No
Name(s) of account holder(s):
3787510258
3787510258
Name 1:

Name 2 (if any):

Please attach an original statement for each account, showing transactions for the last 6 months.
If they have any other accounts, you must give details of these to this Department on a separate
sheet of paper.
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 Your spouse’s, civil partner’s or
Part 8 continued
cohabitant’s work and claim details
43. If they own stocks, shares (including shares in a creamery or Co-op, annuities, bonds, insurance
policies) or investments in the Republic of Ireland or another country, please state:
Name of company:

Number of shares held: ,

Value per share: € , .
Are the stocks/shares Yes No
jointly owned?
Please attach a statement to show details and current market value.
Do they own any other Yes No
shares?
If Yes, please give details on a separate sheet of paper.
44. If they own (share in the ownership) or work a farm or land, please state:
Size of farm or land: acres

Gross yearly income: € , .

Gross yearly income is money they have made from the farm before deducting operating expenses.

6925489711

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 Your spouse’s, civil partner’s or
Part 8 continued
cohabitant’s work and claim details
45. If they own or share in the ownership of property apart from their home, please state:
Type of property:
If this property is jointly owned, please state:
Name 1:

Name 2 (if any):

Address of property:

Property includes but is not limited to an apartment, business property, another house or land
other than that mentioned at question 44.
If this property is rented out, please state:
Income: € , . a week

Current market value: € , , .

Mortgage outstanding: € , , .
Note: If they have other properties, a separate sheet of paper can be used for more details.
46. If they have a room let in the property they are currently residing in, please state:
Income: € , . a week
47. If they have any other income please give details in the box below:

48. If they sold or transferred any property or business in the last three years please give details in
the box below and attach a copy of the deed of transfer:

2336562322

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 Spouse’s, civil partner’s or cohabitant’s
Part 9 payment details
Any increase for a qualified adult which you (the pension claimant) qualify for will be paid direct to
your spouse, civil partner or cohabitant unless they state otherwise. You should show them this
page to let them decide if they want to receive this increase for themselves or if they want you to
receive this increase with your pension, on their behalf.

Declaration of Spouse, Civil Partner or Cohabitant

Important Notice:
The remainder of this page should be filled out by the person named in Part 7.

(a) I, , wish to have any Increase for a

Qualified Adult paid directly to me.

OR

(b) I, , wish to have any Increase for a

Qualified Adult paid directly to the person named in Part 1 with their pension.
If part (a) above has been signed, you can get your payment at a post office of your choice or direct
to your current, deposit or savings account in a financial institution. An account must be in your
name or jointly held by you.
Please complete one option below.
Financial Institution
You will find the following details printed on statements from your
financial institution.
Name of financial institution:

Bank Identifier Code (BIC):

International Bank Account
Number (IBAN):

Name(s) of account holder(s):

Name 1:

Name 2 (if any):

Post Office
Please enter below the name and address of the post office where you wish to collect your
payment.
Post40office
26087name
052 and address:

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Part 10 Checklist
Have you enclosed the following?

— Letter from school or college

You must attach written confirmation from the school or college confirming that any children
aged 18 - 22 listed in Part 4 of this form are in full time eduction.
If you are claiming for Fuel Allowance, please make sure that you have you fully completed
Questions 28 and 29.
If you are claiming an increase for your spouse, civil partner or cohabitant, please enclose
statements from all financial institutions in the name of or jointly held by them, showing the last 6
months transactions.
If you were born, married or entered into a civil partnership or a civil union outside the Republic of
Ireland:
— Your birth certificate
— Your marriage certificate or civil partnership or civil union registration certificate
— Your spouse’s, civil partner’s or cohabitant’s birth certificate
(if applying for an increase for them)
— Your children’s birth certificates (if applying for an increase for them)
Note: No birth certificate is needed if you are already getting Child Benefit.
Original certificates only.

If you are claiming an Increase for a Qualified Adult for your spouse, civil partner or cohabitant
please provide 6 months bank statements.

Please remember to sign the Declaration in Part 1.

If you have any difficulty in filling in this form, please contact your local Citizens Information Centre,
your local Intreo Centre or your local Social Welfare Office.

1728043139

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 Send this completed application form to:
State Pension (Contributory) Section
Social Welfare Services
Department of Social Protection
College Road
Sligo

4136035608

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 Data Protection Statement
The Department of Social Protection administers Ireland’s social protection system. Customers are
023449
required 26
to66provide personal data to determine eligibility for relevant payments/benefits. Personal
data may be exchanged with other government departments and agencies where provided for by
law. Our data protection policy is available at www.gov.ie/dsp/privacystatement or in hard copy.

Explanations and terms used in this form are intended as a guide only and are not a legal interpretation.
20K 11-20 Edition: November 2020
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