Disability Allowance Application Form (DA1)

Published date19 February 2020
IssuerDepartment of Social Protection
Disability Allowance
Application form for
Data Classification R
Social Welfare Services
DA1
What is Disability Allowance?
Disability Allowance is a means tested payment for people with a specified disability whose
household income falls below certain levels.
How do I qualify?
To get Disability Allowance you must:
• have an injury, disease, physical or mental disability, that has continued or may be expected
to continue for at least one year;
• as a result of this disability, medical condition, illness or injury, you must be determined by a
Deciding Officer of the department as being substantially restricted in undertaking work that
would otherwise be suitable for a person of your age, experience and qualifications; and
• be aged between 16 and 66, satisfy a means test and be habitually resident in the State.
What do I need to complete this application form?
• fill in Parts 1 to 7 as they apply to you and your household;
• complete Part 8 checklist and make sure you have all the information and documents listed;
• complete Part 9 outlining your education, work history and how your medical condition affects
your daily life;
• sign the declaration in Part 10;
• sign Part 11a confirming that you allow your doctor to give us the medical information needed
to decide if you qualify;
• you will also need to ask your doctor to complete the medical report contained in Part 11b.
How to complete this application form?
• there is an example on the back of this page that can be used as a guide to fill in this form;
• write with a black ballpoint pen;
• use BLOCK LETTERS and place an X in the relevant boxes; and
• answer all the questions.
How do I apply?
Send this completed form to:
Disability Allowance Section
Social Welfare Services
Government Buildings
Ballinalee Road
Longford
N39 E4E0
How can I get help and further information?
If you need any help to complete this form, please contact the Disability Allowance Section on
(043) 334 0000, or 0818 927770, or your local Intreo Centre, Social Welfare Office or any
Citizens Information Centre. You can find the name and address of your local Intreo Centre or
Social Welfare Office by visiting www.gov.ie/intreo
For more information visit www.gov.ie/da
1692052050
0881234567
Mr. Mrs. Ms.
3. Surname: M U R P H Y
D O N E G A L T O W N
O L D T O W N
1 N E W S T R E E T
7. Your address:
8. Your mobile phone number:
1.
Your PPS Number:
1 2 3 4 5 6 7 T
How to fill in this form
2. Title, insert an X or Other
4. First names:
M A R Y
5. Birth surname: M C D E R M O T T
2 8 0 2 1 9 7 0
6. Your date of birth:
9. Your email address: M M U R P H Y @ W E L F A R E . I E
D O N E G A L
County
specify:
Y
Y
Y
Y
MMDD
0 1 0 1 1 9 9 9
11.
civil partnership or
cohabiting, from what
date?
M A U R E E N
C 1 5 A 9 6 V
Eircode
Single Cohabiting
Married In a Civil Partnership
Separated A surviving Civil Partner
Divorced A former Civil Partner
Widowed
10.
Are you?
12.
Are you in full time
education?
DIPLOMA IN COMPUTER SCIENCE IN DCU
To help us to process your application write letters and numbers clearly and use one
box for each. Please see examples below.
If yes, please provide
details.
X
X
X
Y
Y
Y
Y
MMDD
(you were in a Civil Partnership
that has since been dissolved)
7848052059

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