Carer's Leave Credits Application Form

• Published date: 28 October 2020
• Issuer: Department of Social Protection

Carer’s Leave Credits

Employee’s name:

Employee’s address:

Employee’s telephone no:

To be completed by your employer on your return to work

PPS No:

I/We certify that the above named employee has taken

carer’s leave as follows:

From: To:

Total no. of weeks:

Signed by or for employer:

Send this completed form to:

Department of Social Protection

Government Buildings,

Client Eligibility Services,

Inner Relief Road, Buncrana,

Co. Donegal.

Application form for Carer’s Leave Credits

Name:

(not block letters)

Position in company or

organisation:

Employer’s

Registered No:

Employer’s telephone no:

Employer’s Official

Stamp:

Date:

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 or 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 as a hard copy

0K 10-20 Edition: October 2020

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