Bereavement Grant Application Form – BG1 - Welfare.ie

Application form forBereavement GrantSocial Welfare ServicesBG 1Data Classification RHow to complete this application.• Please tear off this page and use 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.Please note that Bereavement Grant is a contribution based payment. The grantcannot be paid if enough contributions have not been paid.When form is completed, read Part 5 and sign declaration in Part 1.If you need any help to complete this form, please contact your local SocialWelfare Office or Citizens Information Centre.For more information, log on to www.welfare.ie.Important:You must apply within 12 months of the date of death, otherwise you may losepayment.You must enclose a death certificate/coroner interim cert and the funeral bill orreceipt with this application. The funeral bill or receipt must be in your name oryou must provide written permission from the person responsible for the bill,allowing you to claim Bereavement Grant.

How to fill this formTo 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’ orspecify)3. Surname:4. First name(s):5. Your first name as itappears on your birthcertificate:6. Birth surname:7. Your mother’s birthsurname:8. Your date of birth:9. Your address:1 2 3 4 5 6 7 TMr. Mrs. X Ms. OtherM U R P H YM A U R E E NM A R YM C D E R M O T TK E L L Y2 8 0 2 1 9 7 0D D M M Y Y Y YContact Details1 N E W S T R E E TO L D T O W NC O D O N E G A L10.Your telephone number:11.Your email address:O N E N U M B E R P E R B O XM O B I L EO N E N U M B E R P E R B O XL A N D L I N EO N E C H A R A C T E R P E RB O XSAMPLE

Application form forBereavement GrantFor Official Use OnlySocial Welfare ServicesBG 1Data Classification RPart 1Your own details1. Your PPS No.:2. Title: (insert an ‘X’ orspecify)Mr. Mrs. Ms. Other3. Surname:4. First name(s):5. Your first name as itappears on your birthcertificate:6. Birth surname:7. Your mother’s birthsurname:8. Your date of birth:D D M M Y Y Y YContact Details9. Your address:10.Your telephone number:M O B I L EL A N D L I N E11.Your email address:Signature (not block letters)DeclarationI declare that the information given by me on this form is truthful and complete. I understand that ifany 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 beprosecuted. I undertake to immediately advise the Department of any change in my circumstanceswhich may affect my continued entitlement.Date:2 0D D M M Y Y Y YWarning: If you make a false statement or withhold information, you may beprosecuted leading to a fine, a prison term or both.

Part 1 continuedYour own details12.How are you related tothe deceased person?13.Are you responsible forpaying the funeral bill?YesIf ‘Yes’, attach the funeral bill or receipt of payment in your own name.If ‘No’, do you have permission from the next-of-kin to apply for a Bereavement Grant?YesNoIf ‘Yes’, attach the funeral bill or receipt of payment with a letter of authorisation from theperson responsible for paying the funeral expenses.14.Please give the addressyou last lived at, whileinsurably employed ifdifferent from Q9 onprevious page:15.Has there been or will there be a claim for payment in respect of the deceased, from anyother country?YesNoIf ‘Yes’, please give details:NoPart 2Details of deceased person16.Their PPS No.:17.Their surname:18.Their first name(s):19.Their birth surname:20.Their address:21.Their date of birth:D D M M Y Y Y Y

Part 2 continuedDetails of deceased person22.What date did they die?D D M M Y Y Y YPlease attach the original death certificate if the death took place outside the Republic of Ireland.Please note that Bereavement Grant is a contribution based payment. The grant cannot be paidif enough contributions have not been paid.If the deceased person was a child or aged between 18 and 22 and in full-time education, pleaseproceed to Part 4 of the form.23.If they were married or ina civil partnership, fromwhat date?D D M M Y Y Y Y24.If they lived at anotheraddress before the onegiven at Q20, givedetails here:25.If you have not applied for a Bereavement Grant within 12 months of the date of the person’sdeath, please give reason(s) why:26.What was their old socialinsurance number?This number was used before 197927. What was their occupation?28.Did the deceased person work as an employee in Ireland?If ‘Yes’, please state:Employer’s name:YesNoDuration ofemployment:From:To:D D M M Y Y Y Y29.Was the deceased person getting any payment or pension or allowance from this Departmentor from the Health Service Executive?If ‘Yes’, please state:YesNoName of payment:Their claim or referencenumber:Amount:€ , .a week

Part 2 continuedDetails of deceased person30.Did the deceased person ever work and pay social insurance in another country?YesNoIf ‘Yes’, please state:Country where theyworked or lived:Their address while there:In some countries residence alone can provide cover for social insurance.Their social insurancenumber:Period(s) covered From:by social insurance:To:D D M M Y Y Y YNote: A separate sheet of paper can be used for more details if needed.Part 3Details of deceased person’s spouse, civilpartner or cohabitant31.Was the deceasedperson:SingleMarriedSeparatedDivorcedWidowedCohabitingIn a Civil PartnershipA surviving Civil PartnerA former Civil Partner(you were in a Civil Partnershipthat has since been dissolved)If you have ticked one of the boxes at Q31 (excluding “Single”, “Divorced” or “A former civilpartner”), please give the following details for the widowed spouse, civil partner or cohabitant:32.Their PPS No.:33.Their surname:34.Their first name(s):35.Their birth surname:36.Their address (either acurrent address or theirlast address while ininsurable employment):

Part 3 continued37.Their date of birth:38.Their date of death (ifapplicable):39.Their old social insurancenumber, if any:Details of deceased person’s spouse, civilpartner or cohabitantD D M M Y Y Y YD D M M Y Y Y YThis number was used prior to 197940.Their occupation:41.Did the deceased person's spouse work as an employee in Ireland?YesNoIf ‘Yes’, please state:Employer’s name:Duration ofemployment:42.Did they ever work and pay social insurance in another country?If ‘Yes’, please state:Country where theyworked or lived:From:To:Their address while there:D D M M Y Y Y YYesNoIn some countries residence alone can provide cover for social insurance.Their social insurancenumber:Period(s) covered From:by social insurance:To:D D M M Y Y Y YNote: A separate sheet of paper can be used for more details if needed.

Part 4Your payment detailsYour Bereavement Grant may be paid to your current, deposit or savings accountin a financial institution. Please note that the account must remain open untilpayment (if awarded) is made.Financial InstitutionYou will find the following details printed on statements from your financial institution.Name of financial institution:Sort code:Account number:Bank Identifier Code (BIC):International Bank AccountNumber (IBAN):Name(s) of account holder(s):Name 1:Name 2 (if any):Part 5checklistHave you enclosed the following?— Remember in all cases to send a death certificate / coroner's interim certificate and the funeralbill in your name, with your application.— Please get a letter from the school or college if your application is for a child aged between 18and 22 who was in full-time education.Please remember to sign the Declaration in Part 1.If you have any difficulty in filling in this form, please contact your local Social Welfare Office orCitizens Information Centre.Bereavement Grant SectionSocial Welfare ServicesCollege RoadSligoLoCall:Telephone:Send this completed application form to:1890 500 000 (from the Republic of Ireland only)071 9157100 (from the Republic of Ireland only) or+ 353 71 9157100 (from Northern Ireland or overseas)Note:The rates charged for using 1890 (LoCall) numbers may vary among different service providers.Data Protection and Freedom of InformationWe, the Department of Social Protection, will treat all information and personal data you giveas 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.75K 04-13 Edition: April 2013