Social Welfare Services

UP1 JBSE
Application form for Data Classification R

Jobseeker’s Benefit (Self-Employed)

What is Jobseeker’s Benefit Self-employed?

Jobseeker’s Benefit Self-Employed (JBSE) provides income support to self-employed people who have
fully ceased self-employment and have paid Pay Related Social Insurance (PRSI) self-employment
contributions at Class S.
How do I qualify for Jobseeker’s Benefit Self-Employed?
You may be eligible for this scheme if you:
• are between 18 and 66 years of age;
• have fully ceased self-employment activity;
• are genuinely seeking work and are available for full-time work;
• are capable of work; and
• satisfy certain PRSI contribution conditions. You must have paid at least:
• 156 PRSI self-employment contributions at Class S; or
• 104 PRSI self-employment contributions at Class A or H; and
• 52 PRSI self-employment contributions at Class S in the governing contribution year.
Note: The governing contribution year is the second last completed tax year. For example, for a claim
made in 2022 the second last complete tax year is 2020.

How long will the payment last?

The payment will last for six or nine months providing you continue to satisfy the conditions. The number of
months depends on the total amount of PRSI self-employment contributions you have paid. In determining
the length of time, you must have paid:
• at least 260 PRSI contributions at Class S to be eligible for nine months.
• less than 260 PRSI contributions at Class S to be eligible for six months.

How will I be paid?

Jobseeker’s Benefit Self-Employed will be paid into your bank account or to a post office of your choice.
The rate will be based on your self-employment income in the governing contribution year.
You may also qualify for increases for your:
• spouse;
• civil partner;
• partner;
• cohabitant; and
• children.

How can I get help and further information?

Help in completing this form is available from your local Intreo Centre, Social Welfare Branch Office or
any Citizens Information Centre. When completed, send this completed form to your local Intreo Centre or
Social Welfare Branch Office. The name and address of your local Intreo Centre or Social Welfare Branch
Office can be found by visiting www.gov.ie/intreocentres.

For more information, please visit www.gov.ie/jbse.

 How to fill in this form
To help us process this form please write letters and numbers clearly and use one box for
each. See examples below.

Details of you and your spouse, civil

Part 1
partner or cohabitant
If you do not wish to claim for a spouse, civil partner or cohabitant you do not need to fill in their
details or complete Part 6 of this form.

Applicant Spouse, Civil Partner or Cohabitant

1. PPS Number: 1 2 3 4 5 6 7 8 T 8 7 6 5 4 3 2 1 X

First names: M A R Y D A V I D

Surname: N O R T O N N O R T O N

Birth surname: M C D E R M O T T N O R T O N

Mothers birth surname: D E L A N E Y B R A D Y

Date of birth: 1 0 0 5 1 9 7 0 2 3 1 1 1 9 7 5
D D M M Y Y Y Y D D M M Y Y Y Y
Address: 1 N E W 1 5 G R E E N
If you and your S T R E E T A V E N U E
spouse, civil partner
or cohabitant are not O L D T O W N M A I N R O A D
living together give both
addresses. D O N E G A L C A R L O W

County D O N E G A L C A R L O W

Eircode T 4 2 H 6 8 C C 2 7 U 8 3 M

Nationality: I R I S H C A N A D I A N

Occupation: D E N T I S T

Telephone number: 0 8 8 1 2 3 4 5 6 7

Email address: M M U R P H Y @

W E L F A R E . I E

SAMPLE
 Social Welfare Services
UP1 JBSE
Application form for Data Classification R

Jobseeker’s Benefit (Self-Employed)

Details of you and your spouse, civil

Part 1
partner or cohabitant
If you do not wish to claim for a spouse, civil partner or cohabitant you do not need to fill in their
details or complete Part 6 of this form.

Applicant Spouse, Civil Partner or Cohabitant

1. PPS Number:

First names:

Surname:

Birth surname:

Mothers birth surname:

Date of birth:
D D M M Y Y Y Y D D M M Y Y Y Y
Address:
If you and your
spouse, civil partner
or cohabitant are not
living together give both
addresses.

County

Eircode

Nationality:

Occupation:

Telephone number:

Email address:

Single Separated In a Civil Partnership

2. Are you? Married Divorced A surviving Civil Partner
Widowed Cohabiting
A former Civil Partner, meaning
you were in a Civil Partnership
that has since been dissolved.
Page 1
Part 2 Your employment and training details

Some of the following questions may appear similar but they are necessary to complete your application
and to fit our employment support services to your individual needs.

3. Have you made an unemployment claim in the last five years? Yes No

If yes, were you signing on for twelve months or more? Yes No

4. Have you been on a Community Employment (CE) scheme in the

Yes No
last five years?

If yes, were you on this scheme for 12 months or more? Yes No

5. Which of the following categories best describes the highest level of education you have completed?

No education beyond primary or national Leaving Certificate, Matriculation or

school or left school at or before age 15. equivalent or left school at age 18 or 19.

Junior, Intermediate or Group Certificate Third Level Award Certificate, Diploma or

or equivalent, or left school at age 16 or 17. Degree or left education at age 20 or older.

6. Have you completed an apprenticeship training programme and

Yes No
qualified or got your papers?

7. How would the location where you live be described?

A rural area A small town, 2,000 to 10,000 inhabitants.

Town or city, more than 10,000

A village, up to 2,000 inhabitants.
inhabitants.

8. When were you last in paid employment or self-employment?

Still in employment, go to question 9. In the last 5 years, go to question 10.

In the last month, go to question 10. Over 5 years ago, go to question 10.

In the last year, go to question 10. Never, go to question 12.

Less than 1 month. 1 - 2 years.

9. If you are still in employment, how long are you in
your current job? 1 - 6 months. 2 years or more.
6 - 12 months.

Page 2
Part 2 continued Your employment and training details
Less than 1 month. 1 - 2 years.
10. If you are no longer in employment, how long did
your last job last? 1 - 6 months. 2 years or more.
6 - 12 months.

11. If you are in employment, what is your gross

weekly income? € , .
If you are not in employment, what was your gross
weekly income? € , .
Gross weekly income is your weekly earnings before tax, PRSI, union dues or other
deductions.

12. Do you have the use of a car, van or motorcycle? Yes No

13. Can you use public transport in your area? Yes No

14. Have you ever thought about moving location to take up a job? Yes No

15. Have you any difficulty with reading, writing or numbers? Yes No

Very Good. Bad.

16. How would you describe
Good. Very Bad.
your health?
Fair.

Very Good. Bad.

17. How well do you speak
Good. Very Bad.
English?
Fair.

18. Which country were you

born in?

Page 3
Part 3 Your self-employment details
19. Please state:

Business name:

Employer’s Registration
Number:
Business address:

County Eircode

Nature of Business:

20. When did your self-employment cease?

D D M M Y Y Y Y

21. Why did your self-employment cease? Please give details:

22. Do you have a notice of assessment? Yes No

If yes, please submit your most recent assessment.

Page 4
Part 3 continued Your self-employment details
23. What types of self-employment were you doing?

Company director. Sole trader.

Limited company. Investments.

Partnership. Rental income from the

letting of property or land.

Other, please specify:

24. What types of self-employment have now ceased?

Company director. Sole trader.

Limited company. Investments.

Partnership. Rental income from the

letting of property or land.

Other, please specify:

What were the businesses’

trading names?

25. Have you completely ceased trading as a self-employed person? Yes No

Ceased temporarily.
If no, please tick appropriately:
Ongoing but reduced. Seasonal.

Note: You must supply your most recent profit or loss statement if your business is still trading.

26. If it was a limited company,

what was its registered name?

Are you still a company director? Yes No

Page 5
Part 3 continued Your self-employment details
27. Were the premises: Owned Leased Rented

28. When did the business commence trading?

D D M M Y Y Y Y

29. If the business has ceased trading, is it in liquidation? Yes No

If yes, please state the name and address of the liquidator:

Name:

Address:

County Eircode

30. Have you sold your business or a share of it? Yes No

If yes, please state:

The amount you received: € , .

The date of the sale:
D D M M Y Y Y Y

If you have rental property or land, please answer Questions 31 and 32 below.
If otherwise, move on to Question 33.

31. Have you sold these properties? Yes No

If yes, please state the

€ , .
amounts you received € , .
and the dates of sale:
€ , .
D D M M Y Y Y Y
32. If you have not sold these properties, are they rented out or
Yes No
advertised for renting?

If yes, has your rental income increased or decreased Increased

over the last 12 months? Decreased

What is your annual net profit, if any, from these properties? € , .

Page 6
Part 3 continued Your self-employment details

If you have any investments, please answer Question 33 below. If otherwise, move onto Part 4.

33. Have you sold your investments? Yes No

If yes, please state the

€ , .
amounts you received € , .
and the dates of sale:
€ , .
D D M M Y Y Y Y

If no, has your income from your investments increased or decreased Increased
over the last 12 months? Decreased

What is your annual net profit, if any, from these investments? € , .

Page 7
Part 4 Other employment details

Complete Part 4 if you have any other employments now or have had any in the last two years.

Working full-time. CE, SOLAS, or TÚS.

34. What is your employment status? Working part-time. Working casually.

Farming.

If you are currently employed or doing a CE, SOLAS or TÚS scheme, please provide the details asked
for below:

Name of employer:

Address of employer:

County Eircode

Occupation:

Date employment started:

D D M M Y Y Y Y

Work pattern: hours a week. days a week.

Please give details of your employment in the box below. For example, are you on part-time or casual
employment or Short-Time Work Support.

Page 8
Part 4 continued Other employment details
35. Have you had any other employment in Ireland in the last two years? Yes No

If yes, please state:

Name of employer:

Address of employer:

County Eircode

36. Have you had any other employments in another EU country or the
Yes No
UK in the last two years?

If yes, please state:

Country:

Social Security or National

Insurance Number:

Part 5 Details of availability or efforts to find work

37. What type of work are you

looking for?

Are you available for full-time work? Yes No

Are you looking for full-time work? Yes No

Would you accept any other type of work? Yes No

If no, please give details:

Page 9
Part 5 continued Details of availability or efforts to find work
38. Are you currently registered with a school, college, or university? Yes No

If yes, please state:

Name of institution:

Name of course:

Are you registered as: Full-time Part-time Online

Hours of attendance a week:

When will the course end?

D D M M Y Y Y Y

Do you intend to register with a school, college or university in the

Yes No
next academic year?

39. Are you receiving or have you recently applied for any Social Protection
payments including Working Family Payment, from this department or Yes No
from any other EU member state or the UK?

If yes, please state:

Type of payment:

PPS, National Insurance or

Social Security Number:

Weekly amount: € , .
Source of payment:

Country of payment:

40. Is anyone claiming for you as their qualified adult on their Social
Yes No
Protection payments?

If yes, please state:

Type of payment:

Claim number:

Weekly amount: € , .
Their PPS Number:

Page 10
 Your spouse, civil partner or cohabitant’s
Part 6
income details
41. Do you wish to claim an increase for a spouse, civil partner or
Yes No
cohabitant?

If yes, please complete the rest of the questions in Part 6.

If no, please go to Part 7.

42. Does your spouse, civil partner or cohabitant have any accounts in
a bank, building society, post office, credit union or any other financial Yes No
institution in Ireland or any other country or any cash savings?

If yes, please state the total amount of savings: € , .

43. Does your spouse, civil partner or cohabitant have any investments
Yes No
including stocks, bonds or shares in Ireland or any other country?

If yes, please state the total value of investments: € , .

44. Does your spouse, civil partner or cohabitant have earnings or income
from full-time or part-time employment, or self-employment including Yes No
farming in Ireland or any other country?

If yes, please state:

How often they are paid: Weekly Fortnightly Monthly

Their gross weekly income: € , .

Gross weekly income is weekly income before tax, PRSI, union dues or other deductions.

Please attach their latest payslips or Form UP1(f) if self-employed. This form is available from their local
Intreo Centre or Social Welfare Branch Office.

45. Does your spouse, civil partner or cohabitant receive any payment
Yes No
under a Maintenance Grant or a Deed of Covenant?

If yes, please state their total weekly amount: € , .

46. Does your spouse, civil partner or cohabitant have other income from any
Yes No
other sources? For example, compensation, redundancy, private pension.

If yes, please state:

Source of income:

Weekly amount: € , .
Total amount from redundancy or compensation: € , .

Page 11
 Your spouse, civil partner or cohabitant’s
Part 6 continued
income details
47. Does your spouse, civil partner or cohabitant have a social protection
Yes No
payment from Ireland or any other country?

If yes, please state:

Country of payment:

Weekly amount: € , .
Address of issuing office:

County Eircode

PPS or Social Security

Number:

48. Does your spouse, civil partner or cohabitant have any houses,
properties or lands not occupied by them, in Ireland or any other Yes No
country?

If yes, please give details:

49. Do you or your spouse, civil partner or cohabitant receive rental income
Yes No
from the property you are living in?

If yes, does your spouse, civil parnter or cohabitant own the property? Yes No

If no, who owns the

property?

Is the person a family member or employee? Yes No

Family member
If yes, please state their relation to you:
Employee

From what date did the person start renting a room in your home?
D D M M Y Y Y Y
How much rent do you or your spouse, civil partner or cohabitant
receive per week? € , .
Page 12
Part 7 Details of your children
50. Do you wish to apply for an increase for children who normally live with
Yes No
you and who are being supported by you?

Under age 18.

If yes, how many children do you wish to claim for?
Aged 18-22 in full-time education.

Child 1
Surname:

First names:

Relationship to you:

PPS Number:

Child 2
Surname:

First names:

Relationship to you:

PPS Number:

Child 3
Surname:

First names:

Relationship to you:

PPS Number:

Child 4
Surname:

First names:

Relationship to you:

PPS Number:

Child 5
Surname:

First names:

Relationship to you:

PPS Number:

Continued on the next page

Page 13
Part 7 continued Details of your children
Child 6
Surname:

First names:

Relationship to you:

PPS Number:

Child 7
Surname:

First names:

Relationship to you:

PPS Number:

Important information
If you wish to claim an increase for dependent children, while your spouse, civil partner or
cohabitant is in employment or self-employment, you must submit details of their income such as a copy
of their recent payslip or details of their self-employment.

You must attach written confirmation from the school or college for the children aged 18 to 22, if any.

A separate sheet of paper can be used for details of additional children, if any.

Part 8 Late claims

51. If you did not claim when your self-employment ended, please state the reasons why:

Please state the date from which you wish to claim:

D D M M Y Y Y Y

Part 9 Optional Jobseeker’s Allowance

52. Do you wish to apply for Optional Jobseeker’s Allowance if you do

Yes No
not qualify for the full rate of Jobseeker’s Benefit Self-Employed?

Page 14
Part 10 Payment method
You can get your payment direct to your current, deposit or savings account in a financial institution or at
a Post Office of your choice. An account must be in your name or jointly held by you. Please complete one
option below.

Post Office
Name:
Address:

County Eircode

Financial Institution
Name of financial institution:

Bank Identifier Code (BIC):

International Bank Account

Number (IBAN):

Names of account holders:

Name 1:
Name 2, if any:

Page 15
Part 11 Declaration
I declare that:
a) My self-employment activity has ceased.
b) I am capable of, available for and genuinely seeking work.
c) I have not claimed nor am I getting any other benefit, pension or allowance from any source apart from
those shown in this form.
d) I will notify the department if I get work.

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,
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. For example, commencing employment, self-employment or a change in family
circumstances.

Date: 2 0
D D M M Y Y Y Y
Your signature, not capital letters.

If you are not able to sign, your mark should be made and witnessed. The witness should sign below.

Date: 2 0
D D M M Y Y Y Y
Signature of witness, not capital letters.

Name of witness:

Address of witness:

County Eircode

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

Page 16
Part 12 Record of mutual agreements
Between: The Department of Social Protection and

Name:

PPS Number:

The department is committed to providing comprehensive employment support and income support
services to its customers. Our goal is to help our customers in two ways: firstly, by providing income
supports during periods of unemployment; and secondly by helping customers find work.
In return we would like you, our customer, to commit yourself to work with us as we work to help you. The
document on this page records our mutual obligations to each other.

Our promise to you Your promise to us

• We will do all we can to process claims as • I will work to secure employment at the
quickly and as efficiently as possible. earliest possible opportunity.
• We will pay income support payments as • I will work with the department to agree my
provided for in legislation in an efficient and Personal Progression Plan.
timely manner. • I will attend meetings when invited by the
• We will work to identify suitable department.
employment, work experience or training, • I will follow up on all suggestions and take
educational and personal development up any work placement, work experience,
opportunities for you. training or personal development places
• We will work with you to help you prepare notified to me by the department.
your Personal Progression Plan to assist • I will inform the department immediately if I
you to take the right steps to employment. find work, or if I am no longer available for
• We will monitor and review progress work.
against this plan with you. • I will treat the staff of the department
• We will meet with you normally by with dignity and respect and honour the
appointment and give you fair notice of all confidentiality of my relationship with it.
such appointments. • I will provide the department with all
• We will treat you with dignity and information requested to assess any claim for
respect and honour the confidentiality of income support.
our relationship. • I will abide by the declaration in my
Jobseeker’s Allowance, Jobseeker’s Benefit
or Jobseeker’s Benefit Self-Employed
application form.

By signing below, I understand that failure to adhere to my promises may result in the reduction or
withdrawal of any income support payments which would otherwise be due to me and that I could be
prosecuted for making a false declaration or withholding information in relation to my claim.

Signature for and on behalf of the department. Your signature.

Page 17
Part 13 Checklist
Have you:

• Answered all the questions that apply to you?

• Submitted your most recent Notice of Assessment if you have one? See Question 22.

• If you are claiming for children between 18 and 22 years of age who are in full-time education,
included a letter from their school or college? See Part 7.

• Provided the details of where you would like to receive your payment? See Part 10.

• Signed the declaration? See Part 11.

• Signed the Record of Mutual Commitments? See Part 12.

Note:
Depending on your circumstances, some or all of your Jobseekers Benefit Self-Employed payment may
be liable to income tax. However, tax is not charged on increases paid for any dependent children, or on
the first €13 per week of your payment. PRSI and USC are also not charged on payments.

The department pays Jobseekers Benefit Self-Employed without deducting tax. However, the department
notifies the Office of the Revenue Commissioners of the taxable amount of the payment to be taken into
account for income tax purposes. This means you do not have to do anything for the correct tax to be
paid.

Information about the taxation of social protection payments is available from the Office of the Revenue
Commissioners and on the Jobs and Pensions page:
www.revenue.ie/en/jobs-and-pensions.

Please bring or post this completed application form, along with the relevant supporting documents as
listed on the form, to your local Intreo Centre or Social Welfare Branch Office. You can find the name and
address by visiting www.gov.ie/intreocentres.

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 01-23 Edition: January 2023
Page 18