Social Welfare Services

Application form for

HRC 1
Data Classification R

Habitual Residence Condition

Thank you for your application for

D D M M

on

Y Y Y Y . However, we need more information to decide whether

you are habitually resident in the Republic of Ireland. Please answer the questions in this form to help us decide this issue. How to complete application form for Habitual Residence Condition. Please use this page as a guide to filling in this form. Please use blaCk ball point pen. Please use BLOCK LETTERS and place an X in the relevant boxes. Please answer all questions that apply to you. You need a Personal Public Service Number (PPS No.) before you apply. applicant: Fill in all Parts. When form is completed, sign declaration in Part 1. If you fail to answer all questions, your application will be delayed. If you need any help to complete this form, please contact your local Social Welfare Office or Citizens Information Centre. For more information, log on to www.welfare.ie.

How to fill in first page of 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 No.: 2. Title: (insert an X or specify) 3. Surname: 4. First name(s): 5. Your first name as it appears on your birth certificate: 6. Birth surname: 7. Your mothers birth surname: 8. Your date of birth: 1 2 3 4 5 6 7 T Mr. Mrs. X Ms. Other

M U R P H Y M A U R E E N M A R Y M C D E R M O T T K E L 2 8 D D L Y 0 2 M M 1 9 7 0 Y Y Y Y

Contact Details
9. Your address: 1 N E W S T R E E T

O L D C O

T O W N D O N E G A L

10.Your telephone number:

0 8 6 1 2 3 4 5 6 7 MOBILE 0 1 7 0 4 3 0 0 0 LANDLINE

11.Your email address:

M M U R P H Y @ W E L

F A R E

SAMPLE

Social Welfare Services

Application form for

HRC 1
Data Classification R

Habitual Residence Condition

Part 1
1. Your PPS No.: 2. Title: (insert an X or specify) 3. Surname: 4. First name(s): 5. Your first name as it appears on your birth certificate: 6. Birth surname: 7. Your mothers birth surname: 8. Your date of birth: D D M M Y Y Y Y Mr. Mrs. Ms. Other

Your own details

Contact Details
9. Your address:

10.Your telephone number: MOBILE LANDLINE 11.Your email address:

Declaration
I declare that all the information I have given on this form is accurate. Date: D D
Signature (not block letters)

2 0
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.

Part 1 continued
12.Are you?

Your own details

Single Married Separated Divorced Widowed Cohabiting In a Civil Partnership A surviving Civil Partner A former Civil Partner (you were in a Civil Partnership that has since been dissolved)

If you are: Married or entered into a civil partnership, from what date? D D Cohabiting, from what date? D D M M Y Y Y Y Separated, divorced or civil partnership dissolved, from what date? D D M M Y Y Y Y A copy of your divorce or separation papers must be submitted with your claim. Well Very Well Not Well Not at all M M Y Y Y Y

13.How well do you speak English? 14.Country were you born in? 15.Your nationality?

The European Economic Area (EEA) comprises the Member States of the European Union together with Iceland, Norway and Liechtenstein. 16.If you are not an EEA national, do you hold a current: Irish Residence Permit Yes No (Stamp 4)? Irish Employment Permit Yes No (Stamp 1)? Student Visa (Stamp 1A, Yes No Stamp 2, Stamp 2A, Stamp 3)? If Yes to either question, please enclose your original permit and your original letter from Department of Justice, which sets out the reasons you have been granted permission to reside in the Republic of Ireland. If No to either question, have you applied for permit renewal? Yes No Please give further details as to your residence and/or employment status, and enclose any relevant documentation (e.g. your original most recent permit and a copy of your renewal application). 17.Do you have a current GNIB Card? Yes No If Yes, please state: Your GNIB Number:

Part 1 continued

Your own details

18.Have you lived in the Republic of Ireland previously? No Yes If Yes, please complete fully the remainder of this section. If No, please go to question 23. 19.Dates of previous residence: From: To: D D M M Y Y Y Y 20.How did you support yourself when you lived in the Republic of Ireland?

21.Why did you leave the Republic of Ireland?

22.How did you support yourself while you were abroad?

23.When did you come to live or return to live in the Republic of Ireland? D D M M Y Y Y Y Other

24.Why did you come or return to the Republic of Ireland? Study Work Family If Other, please give details:

25.How do you plan to support yourself in the Republic of Ireland? (Include details of funds you can access)

Part 1 continued

Your own details

26.Have you lived in the Republic of Ireland continuously since the date you came to live here or returned to live here? Yes No If Yes, please provide proof of residency, for example, a tenancy agreement. 27.Please give details of each country, outside the Republic of Ireland, that you have lived in. Country 1 Country: Dates you lived there: From: To: D D Why did you live there? M M Y Y Y Y

Country 2 Country: Dates you lived there: From: To: D D Why did you live there? M M Y Y Y Y

Country 3 Country: Dates you lived there: From: To: D D Why did you live there? M M Y Y Y Y

Part 1 continued
Country: Dates you lived there: From: To:

Your own details

Country 4

D D Why did you live there?

M M

Y Y Y Y

Note: A separate sheet of paper can be used for more details if needed. 28.Do you own or have you ever owned property in the Republic of Ireland? Yes No If Yes, please state: Address of the property:

Are you living in the property? Is the property rented? Have you sold the property?

Yes Yes Yes

No No No

29.Do you own or have you ever owned any kind of property, lands or business abroad? Yes No If Yes, please state: The address:

Did you ever live there? Is it rented? Was it sold?

Yes Yes Yes

No No No

Part 1 continued

Your own details

30.Do you have bank accounts in other countries? No Yes If Yes, please give details:

31.How long do you plan to stay in the Republic of Ireland? 0-1 year 1-2 years If Over 5 years, please give details:

3-5 years

Over 5 years

32.Do you belong to any professional bodies, community groups, social or sports organisations in the Republic of Ireland? No Yes If Yes, please give details:

33.Have you ever been imprisoned in the Republic of Ireland? No Yes If Yes, please give details:

Part 2 continued

Your work details

34.Did you arrange employment prior to coming to the Republic of Ireland? Yes No If Yes, please give details:

35.Have you always worked since coming to the Republic of Ireland? Yes No 36.Are you employed at present in the Republic of Ireland? Yes No If Yes, please state: Employers name: Employers address:

When employment started: D D M M Full-time Is your employment: Have you a written contract of employment? Yes How long is the job likely to last? D D M M Y Y Y Y Part-time No Y Y Y Y

37.Please give details of all your previous employments in the Republic of Ireland, starting with your first employer. Employer 1 Employers name: Employers address:

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

Part 2 continued
Employers name: Employers address:

Your work details

Employer 2

Job title: Dates you worked there: From: To: D D M M Y Y Y Y Note: A separate sheet of paper can be used for more details if needed. 38.If you worked in the United Kingdom please give your United Kingdom social services number: 39.Are you self-employed at present in the Republic of Ireland? No Yes If Yes, please state: Type of work you do: Date you started self-employment:

D D

M M

Y Y Y Y

40.Were you ever self-employed in the Republic of Ireland? Yes No If yes, please state: Type of work you do: Dates of self-employment: From: To: D D M M Y Y Y Y 41.If you have never worked in the Republic of Ireland, have you looked for work since coming here? Yes No If Yes, please give details:

Part 3
42.Their PPS No.: 43.Title: (insert an X or specify) 44.Their surname: 45.Their first name(s): 46.Their birth surname: 47.Their mothers birth surname: 48.Their date of birth:

Your spouses, civil partners or cohabitants details

Mr.

Mrs.

Ms.

Other

D D 49.Their nationality:

M M

Y Y Y Y

50.Do they live in the Republic of Ireland with you? Yes No If Yes, please state: Date their current stay in the Republic of Ireland D D M M Y Y Y Y began: If No, please state where they are and any plans you have made for them to join you:

Part 4

Your spouses, civil partners or cohabitants work and claim details

51.Did they arrange work prior to coming to the Republic of Ireland? Yes No If Yes, please give details:

52.Have they always worked since coming to the Republic of Ireland? Yes No 53.Are they employed at present in the Republic of Ireland? Yes No If Yes, please state: Employers name: Employers address:

When employment started: D D M M Full-time Is their employment: Have they a written contract of employment? Yes How long is the job likely to last? D D M M Y Y Y Y Part-time No Y Y Y Y

Part 5

Details of your qualified child(ren)

54.Do you have children or Yes No other dependants? If Yes, please state child or dependants: Child or dependant 1 Surname: First name(s): Date of birth: D D Surname: First name(s): Date of birth: D D Surname: First name(s): Date of birth: D D M M Y Y Y Y Note: A separate sheet of paper can be used for more details if needed. 55.Do your children or other dependants live in the Republic of Ireland with you? Yes No If No, please state where they are and any plans you have made for them to join you: M M Y Y Y Y Child or dependant 3 M M Y Y Y Y Child or dependant 2

Part 5 continued

Details of your qualified child(ren)

56.Are your children in school in the Republic of Ireland? Yes No If Yes, please state: Child 1 Childs surname: Childs name: Name of school: Address of school:

Start date: D D Child 2 Childs surname: Childs name: Name of school: Address of school: M M Y Y Y Y

Start date: D D Child 3 Childs surname: Childs name: Name of school: Address of school: M M Y Y Y Y

Start date: D D M M Y Y Y Y Note: A separate sheet of paper can be used for more details if needed.

Part 6

Details of other family members

57.Does any of your close family, for example parent, brother, sister or child, live in the Republic of Ireland? No Yes If Yes, please state: Person 1 Their PPS No.: Their surname: Their first name(s): Their date of birth: D D Their address: M M Y Y Y Y

Their relationship to you: Date they came to the Republic of Ireland:

D D Person 2

M M

Y Y Y Y

Their PPS No.: Their surname: Their first name(s): Their date of birth: D D Their address: M M Y Y Y Y

Their relationship to you: Date they came to the Republic of Ireland:

D D

M M

Y Y Y Y

Part 6 continued
Their PPS No.: Their surname: Their first name(s): Their date of birth:

Details of other family members

Person 3

D D Their address:

M M

Y Y Y Y

Their relationship to you: Date they came to the Republic of Ireland:

D D Person 4

M M

Y Y Y Y

Their PPS No.: Their surname: Their first name(s): Their date of birth: D D Their address: M M Y Y Y Y

Their relationship to you: Date they came to the Republic of Ireland:

D D

M M

Y Y Y Y

Part 6 continued
Their PPS No.: Their surname: Their first name(s): Their date of birth:

Details of other family members

Person 5

D D Their address:

M M

Y Y Y Y

Their relationship to you: Date they came to the Republic of Ireland:

D D M M Y Y Y Y Note: A separate sheet of paper can be used for more details if needed.

58.Does any of your close family, for example parent, brother, sister or child, live outside the Republic of Ireland? No Yes If Yes, please state: Person 1 Their surname: Their first name(s): Their address:

Their relationship to you: Person 2 Their surname: Their first name(s): Their address:

Their relationship to you:

Part 6 continued
Their surname: Their first name(s): Their address:

Details of other family members

Person 3

Their relationship to you: Note: A separate sheet of paper can be used for more details if needed.

Part 7

Checklist

Have you enclosed the following? Your residence permit or renewal application Your work permit Your GNIB documents If born, married or entered into a civil partnership or civil union outside the Republic of Ireland: Your birth certificate Your spouses, civil partners or cohabitants birth certificate Your marriage certificate or civil partnership or civil union registration certificate Your divorce, dissolution of civil partnership or separation documents Only original certificates will be accepted

Please remember to sign the declaration in Part 1.

Data Protection and Freedom of Information We, the Department of Social Protection, will treat all information and personal data you give as confidential. We will only disclose it to other people or bodies according to the law. Explanations and terms used in this form are intended as a guide only and are not a legal interpretation.
150K 06-11 Edition: June 2011