Social Welfare Services

RS 1
Application form for Data Classification R

Rent Supplement
What is Rent Supplement?
Rent Supplement is a means tested payment for people living in private rented accommodation
who cannot provide for the cost of their accommodation. Please note, if you are already receiving
Housing Assistance Payment (HAP) from your Local Authority, you do not qualify for Rent
Supplement.
How do I qualify for Rent Supplement?
You can qualify for Rent Supplement if you:
• are renting accommodation;
• satisfy a means test; and
• you were previously in receipt of a Rent Supplement payment within 12 months of the date of
application; or
• you have been renting for a period of six months (183 days) within the past 12 months of the
date of this application, are experiencing a substantial change in your circumstances and are
now unable to pay the rent.
How much will I receive?
The amount of Rent Supplement provided to you by the Community Welfare Service is based on:
• the amount of rent you pay;
• where you live;
• your household’s income; and
• your family circumstances.
A contribution towards the rent is expected of everybody in receipt of rent supplement - this
contribution will be calculated on a household’s income.
How long will the payment last?
Rent Supplement will last for as long as you continue to meet the conditions of the scheme.
You must notify the department if your circumstances change, for example employment,
self-employment, full-time education, or any other change in your household’s income.
Where can I get more information?
The Community Welfare Service in your local Intreo Centre can provide all information on Rent
Supplement. They can explain the process and supply an application form.
How to complete this application form?
• You need a Personal Public Service (PPS) Number before you apply.
• Write with a black ballpoint pen, use capital letters and place an X in the relevant boxes.
• Answer all questions that apply to you.
How can I get help and further information?
Help in completing this form is available from your local Intreo Centre, Social Welfare Office or any
Citizens Information Centre. When completed, send your form to your local Intreo Centre or Social
Welfare Office. The name and address of your local Intreo Centre or Social Welfare Office can be
found by visiting www.gov.ie/intreo
For more information visit www.gov.ie/RENT
 How to fill in this form
To help us to process your application write letters and numbers clearly and use one box
for each. Please see examples 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 names: M A U R E E N
5. Your name as it appears M A R Y M C D E R M O T T
on your birth certificate:
6. Birth surname: M C D E R M O T T

7. Your date of birth: 2 8 0 2 1 9 7 0

D D M M Y Y Y Y
8 . Your mother’s birth K E L L Y
surname:
9. Your nationality: I R I S H
10. Do you have a social security number from another country? X Yes No
If yes, please state:
Social Security Number: J D 2 3 6 8 7 5 B

Country: E N G L A N D
11. Do you have an Irish Residence Permit? X Yes No

Contact Details
12. 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 Eircode A 6 5 F 4 E 2

13. Your telephone 0 8 8 1 2 3 4 5 6 7 Mobile

number:
0 1 3 2 1 1 2 3 4 L andline

14. Your email address: M M U R P H Y @ W E L F A R E . I E

SAMPLE
 Social Welfare Services
For Official Use Only
RS 1
Application form for Date received Data Classification R

Rent Supplement By whom

HRC
Satisfied o
Part 1 Your own details HRC1 issued o
1. Your PPS Number:
2. Title insert an X Other
Mr Mrs Ms
or specify:
3. Surname:
4. First names:
5. Your name as it appears
on your birth certificate:
6. Birth surname:
For official use only:
7. Your date of birth: D D M M Y Y Y Y verified yes (y) or no (n)

8. Your mother’s birth surname:

9. Your nationality:
10. Do you have a social security number from another country? Yes No
If yes, please state:
Social Security Number:
Country:
11. Do you have an Irish Residence Permit? Yes No
Contact Details
12. Your address:

County Eircode

13. Your telephone Mobile

number: Landline
14. 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.
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.
Page 1
Part 1 continued Your own details
15. Do you live alone? Yes No
16. Are you? Single Separated In a Civil Partnership
Married Divorced A surviving Civil Partner
Widowed Cohabiting A former Civil Partner (you were in a Civil
Partnership that has since been dissolved)
17. Are you in full time Yes No
education?
If yes, please provide
details:

18. Are you currently involved in an industrial dispute? Yes No

19. Provide your most recent employment details:
Your current or last
employer’s name:
Your current or last
employer’s address:

Your current or previous weekly gross income: € , .

Number of days worked per week: Number of hours worked per week:
Your current or previous weekly cost of travel to work: € , .
Have you had a substantial reduction in your income or wages? Yes No
If yes, provide your weekly gross income prior to the substantial
reduction in your income: € , .
20. Have you been made unemployed? Yes No
If yes, provide the date of your last wage or salary payment D D M M Y Y Y Y

Amount of your last weekly gross wage or salary received: € , .

Frequency of this payment: Weekly Fortnightly 4 Weekly Calendar Month
Why did this job finish?

21. If you are self-employed, including farming, please state:

Type of business or trade:

Your profit over the last year: € , .

Note: Attach your profit and loss statement for the last 12 months, together with your most
recent notice of assessment from the Office of the Revenue Commissioners.
22. Do you have income or applied for income from any other sources including maintenance,
foreign income, pension, occupational pension, casual or seasonal employment
or any type of social welfare payment including outside of the State? Yes No
If yes, please provide
details in the space
provided:
Page 2
Part 2 Your spouse’s, civil partner’s or cohabitant’s details
23. Their PPS Number:
24. Title, insert an X or specify: Mr Mrs Ms Other

25. Their surname:

26. Their first names:

For official use only:
27. Their date of birth: D D M M Y Y Y Y verified yes (y) or no (n)
28. Your partner’s, spouse’s or cohabitant’s most recent employment details:
Their current or last
employer’s name:
Their current or last
employer’s address:

Their current or previous weekly gross income: € , .

Number of days worked per week: Number of hours worked per week:

Their current or previous weekly cost of travel to work: € , .

Have they had a substantial reduction in their income or wages? Yes No
If yes, provide their weekly gross income prior to the substantial
reduction in income: € , .
29. Are they currently involved in an industrial dispute? Yes No
30. Have they been made unemployed? Yes No
If yes, provide the date of their last wage or salary payment: D D M M Y Y Y Y

Amount of their last weekly gross wage or salary received: € , .

Frequency of this Weekly Fortnightly 4 Weekly Calendar Month
payment:
Why did this job finish?

31. If they are self-employed, including farming, please state:

Type of business or trade:

Their profit or loss over the last year: € , .

Note: Attach their profit and loss statement for the last 12 months, together with their most
recent notice of assessment from the Revenue Commissioners.
32. Have they income or applied for income from any other sources including maintenance, foreign
income, pension, occupation pension, casual or seasonal employment or any type of social
welfare payment including outside of the State? Yes No
If yes, please provide
details in the space
provided:
Page 3
Part 3 Capital assessment details
A separate sheet of paper can be used for more details if required for this section.
33. Have you, your spouse, civil partner or cohabitant received, or due to receive, redundancy
payments?
Yes No
If yes, provide details in the table below.
Redundancy Amount
Recipient (Received or Due) Date Paid or Due Date

You
Your spouse, civil partner or cohabitant
Attach original written confirmation or documentation showing redundancy or settlement payments.
34. Do you, your spouse, civil partner or cohabitant have savings or accounts in a bank, post office,
building society, credit union or any other financial institution in Ireland or another country?
Yes No
If yes, provide the requested details in the table below.
Name of Financial Institution Current Balance € Account Holder Name

Attach an original statement for each account showing transactions for the last six months.

35. Do you, your spouse, civil partner or cohabitant own stocks, shares, including shares in a creamery
or co-op, annuities, bonds, prize bonds, insurance policies or investments? Yes No

If yes, state their current market value: € , .

Attach statements to show details and current market value.
36. Do you, your spouse, civil partner or cohabitant own or share in the ownership of any property,
including land, other than the house you occupy, including any foreign properties owned?
Yes No
If yes, provide the requested details in the table below:
Address Current Value Use or Monthly Rental Income

Page 4
Part 4 Shared accommodation details
37. How many children do you have? under age 18 age 18 to 22 in
full-time education

Note: You must attach written confirmation from the school or college for children aged 18 to 22.
Provide details of children under 18 years of age or 18 to 22 years of age who are in full-time
education and are dependent on you.
Does this
Date of Relationship child live
First Name Surname PPS Number
Birth to you with you?
Yes or No

38. Apart from your spouse, civil partner, cohabitant and children listed previously, state who else
lives with you.
Primary
source
of income,
Amount of
Date of Relationship for example,
First Name Surname rent they pay
Birth to you wage, social
weekly
welfare
payment,
pension

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

Page 5
Part 5 Your accommodation details
39. Are you currently in an accommodation provided by the local authority,
including the Housing Assistance Payment Scheme (HAP), the Rental Yes No
Accommodation Scheme (RAS) or a Local Authority House?
40. Have you been in receipt of Rent Supplement within the last 12 months? Yes No

41. Have you applied for accommodation to any local authority? Yes No
If yes, please provide the following details.

Most Preferred Area of Choice to Live Local Authority Date of Application

42. Have you been assessed by the local authority in the area in which you Yes No
intend to live?
If yes, please provide the letter from the local authority confirming your housing need assessment.

43. Have you been offered accommodation, including HAP or RAS, by a Yes No
local authority?
If yes, provide the following details.

Accommodation Address Local Authority Date of Offer

44. Have you vacated any accommodation provided by a local authority, Yes No
including HAP, RAS or equivalent schemes, either in the State or abroad?
If yes, provide the following details.

Accommodation Address Local Authority Date Vacated

45. Have you vacated any property owned by you, either in the State or abroad? Yes No
If yes, provide details below.

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

Page 6
Part 6 Your preferred payment option
46. Insert an X for which payment method you would prefer and fill in the details below.
1. Payment at a post office
2. Electronic Fund Transfer (EFT) to your financial institution
3. Nominated payment to a third party, for example, landlord’s financial institution

Note: Final decision on payment method is a matter for the Department of Social Protection.

Post Office
Post office name and address:

County Eircode

Financial Institution
Note: You will find the details requested below printed on statements from your financial institution.
Nominated Payment: Your payment can be made to a third party with your consent.
If you wish your payment to go to a third party please provide the following details and sign the
declaration below.

Name of financial institution:

Address of financial
institution:

County Eircode
Bank Identifier Code (BIC):
International Bank Account
Number (IBAN):

Names of account holders:

Declaration of payment to a third party

I wish to have Rent Supplement paid to a third party.

You must sign this declaration to let us know that you want to have the Rent Supplement payment
made to a third party.

Data Protection Statement

The Department of Social Protection administers Ireland’s social protection system. Customers are
required to provide personal data to determine eligibility for relevant payments and 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.
00K 08-21 Edition: August 2021
Page 7
Part 7 Checklist

Please read this section carefully

Essential documents required for your claim.
Photographic ID:
• If you have a Public Service Card (PSC), photographic ID is not required. If you do not have
a PSC, your passport, driver’s licence or other official photographic ID may be supplied.
Evidence required for residence period:
• If you are not currently receiving rent supplement or haven’t previously received rent
supplement in the last 12 months, you must be able to provide evidence of your rental
payments to your landlord for 6 out of the previous 12 month period.
Evidence of tenancy:
• Tenancy agreement signed by you and your landlord.
• Bank statement showing rental payments made.
• Rent book, signed and dated by landlord, if available.
• Two utility bills being paid by you or your spouse, civil partner or cohabitant at your
tenancy’s address.
• Proof of ownership from your landlord such as registration with the Residential Tenancies
Board (RTB), or previous lease.
Proof of your household income:
• Six months of financial statements for all accounts held by you, your spouse, civil partner, or
cohabitant, from a bank, credit union or any financial institution.
• Statements of all stocks, shares held by you, your spouse, civil partner or cohabitant.
Other supporting documentation required if you, your spouse, civil partner or cohabitant:
• Have received a redundancy payment in connection to your recent unemployment, provide
correspondence from your employer supporting your redundancy amount.
• Are self-employed, provide the profit and loss statement for the last 12 months, together with
the most recent notice of assessment from the Revenue Commissioners.
• Have any employed person residing with you over 18 years of age, provide their most recent
payslips or financial statements showing salaries or wages details. This does not include
children 18 to 22 years of age who are in full-time education.
• Have any outstanding mortgages for any property, including land or any foreign property,
please provide documentation showing details.

Ensure that your landlord or agent answers all the questions set out in Part 8 of this form.

Please remember to sign the Declaration in Part 1

Failure to declare all your means and provide evidence of them, could result in a delay in
processing your application.

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

Page 8
Part 8 Landlord or landlord’s agent details
This section should be completed by your landlord or their agent
To process Rent Supplement applications, the Department of Social Protection must
establish the ownership of the property by the landlord.
Examples of documents that can be provided include:
1. Receipt of Local Property Tax (LPT) paid by the landlord.
2. Evidence of buildings insurance policy held by the landlord.
3. Evidence of registration with the Residential Tenancies Board (RTB).
The documents provided can be photocopies and must show the landlord’s name, the
tenancy’s address and be dated within the last 12 months.
If you are providing documents other than the above, contact the community welfare service
and they will assist you if you have any concerns.
Please note you must provide personal details, including your name, address and PPS
Number for the rent supplement claim to be fully processed.
1. In relation to the accommodation rented or leased, please state:
Address of Tenancy Furnished Type: House Number of
Yes or No or Apartment Bedrooms

2. How much is the rent, exclusive of heating, lighting and

other service costs? € , .
3. Is the rent payable? Weekly Four Weekly Calendar Month

If other, provide details:

4. Date tenancy started: D D M M Y Y Y Y

5. Is there a tenancy agreement for this accommodation? Yes No
6. Apart from the tenant, spouse, civil partner or cohabitant and their children, is Yes No
the tenancy’s address shared with other people? If yes, please state:
First Names Surname

7. Has the rent been paid up to date? Yes No

If yes, please state the amount
and date of last payment: € , . D D M M Y Y Y Y

Up to what date has the rent been paid? D D M M Y Y Y Y

If no, please state the amount
of rent outstanding and the last € , . D D M M Y Y Y Y
payment date rent was made to
you by the tenant:
Page 9
Part 8 continued Landlord or landlord’s agent details
8. Is a deposit paid or payable? Yes No
If yes, please state amount
and date paid or due date: € , . D D M M Y Y Y Y

9. Landlord’s full name:

10. Landlord’s home address:

County Eircode

11. Landlord’s telephone number:

12. Landlord’s tax reference number, normally PPS Number:

13. Agent’s full name:

14. Agent’s address:

County Eircode

Declaration by landlord or agent

I confirm that the applicant is renting or leasing and occupying living accommodation from me and
that the information supplied by me is correct and accurate. I undertake to inform the department
immediately of any changes to the information provided above.

Landlord or landlord’s agents official

stamp.
Landlord or landlord’s agent’s signature, not block letters.

Date: D D M M Y Y Y Y

Warning: If you make a false statement or withhold information, you may be prosecuted leading to
a fine, a prison term or both.

Data Protection Statement

The Department of Social Protection administers Ireland’s social protection system. Customers are
required to provide personal data to determine eligibility for relevant payments and 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.
00K 08-21 Edition: August 2021

Page 10