D9182 Claim for compensation of Funeral Expenses and ...

SECTION D continuedDEPENDANTS DETAILSDependant 341 Full nameTitle Mr Mrs Miss Ms OtherSurnameGiven name(s)42 Home addressPOSTCODE43 Postal addressPOSTCODE44 Contact details Home telephone [ ]Work telephone [ ]MobileFacsimile [ ]E-mail45 Date of birth / /46 Gender Male Female47 Relationship to deceased(e.g. partner, son, daughter).Please attach a copy of relevant information to verify relationship e.g. birth certificate48 Was dependant 3 living withthe deceased immediatelybefore the date of death?NoYes49 Was dependant 3 dependenton the deceased foreconomic support at thedate of death?No Yes Wholly Mainly PartlyIf between the ages of 16 and 25 years, is this dependant a student?No Yes Full time Part timeOther Dependants50 Are you aware of any otherdependants?NoYesPlease provide the following details so that DVA can forward theappropriate formDependant’s nameDependant’s addressPOSTCODEContact Phone Nos. [ ][ ]D9182 11/13 P9 of 12