Direct Payment to an Account in a Financial Institution Application Form (DIR PMT1)

Published date06 July 2021
IssuerDepartment of Social Protection
Page 1
2 0 Y Y
Application form for
Direct Payment to an Account
in a Financial Institution
Part 1 Your details
1. PPS Number:
2. Surname:
3. First names:
I wish to have my social protection payment paid directly into my account. I declare that the information I
have given on this form is accurate. I will tell the department when my circumstances change.
Signature, not capital letters.
Date: D D M M
7. Email address:
5. Address:
Declaration
Warning: If you make a false statement or withhold information, you may be prosecuted
leading to a fine, a prison term or both.
This form is used for you to apply to get your social protection payment direct to your current,
deposit or savings account in a financial institution. To help us to process your application:
write letters and numbers clearly and use one box for each;
write with a black ballpoint pen; and
use capital letters.
6 . Telephone number:
Data Classification R
Social Welfare Services
DIR PMT 1
County Eircode
4. Date of birth: Y Y Y YD D M M
8. What social protection
payment are you
getting?

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