Adoptive Leave Credits Application Form

• Published date: 23 March 2021
• Issuer: Department of Social Protection

Adoptive Benefit

To be completed by your employer when you return to work.

To qualify for credits, unpaid adoptive leave must be taken

immediately before* or after paid adoptive leave.

* Foreign adoption only. I/

We certify that the above employee has taken unpaid adoptive

leave as follows, do not include the date your employee was

getting Adoptive Benefit:

Application for adoptive leave credits

Name:

Address:

PPS No.:

Telephone No.:

From: To:

Total number of weeks of unpaid adoptive leave taken:

Signed by or for employer

Signature (not block letters)

Employer’s official

stamp

Position in company or organisation

Date:

Employer’s registered No.:

Telephone No.:

Email address:

Send the completed form to:

Adoptive Benefit Section, Department of Social Protection, McCarter’s

Road, Buncrana, Co. Donegal, F93 CH79.

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.

00K 01-21 Edition: January 2021

Explanations and terms used in this form are intended as a guide only and are not a legal

interpretation.