Domiciliary Care Allowance Application Form (Dom Care 1)

Published date09 April 2021
IssuerDepartment of Social Protection
What is Domiciliary Care Allowance?
Domiciliary Care Allowance (DCA) is a monthly payment for a child with a severe disability. The DCA
payment is not based on the type of disability, it is based on the impact of the disability.
There is more information, including definitions of severe and substantially, in the Domiciliary Care
Allowance Medical Guidelines visit our website, www.gov.ie.
How do I qualify?
Your child must be under 16 (at 16, the child can apply for a Disability Allowance).
Your child’s mental or physical disability must be severe.
The disability must be likely to last for at least one year.
Your child must need ongoing care and attention substantially over and above the care and
attention usually required by a child of the same age.
Your child must be habitually resident in the Irish State.
Your child must live at home with the person claiming the allowance for 5 or more days a
week.
In addition, the person claiming the allowance for the child must:
Provide for the care of the child and habitually reside in the State.
How to Apply?
You need a Personal Public Service Number (PPS No.) before you apply.
How to complete this application form.
Please tear off this page and use as a guide to filling in this form.
Please use BLACK ball point pen.
Please use BLOCK LETTERS and place an X in the relevant boxes.
Please answer all questions that apply to you. If a question does not apply to you, please
leave the answer area blank.
Applicant: Should complete Parts 1 to 5.
The child’s G.P./Specialist should complete Parts 6 and 7.
Please let us know your mobile phone number and we will text you right away confirming that we
received your application.
Note: If your child has a pervasive developmental disorder (PDD), e.g. Autism Spectrum Disorder,
you may wish to have the medical professional or specialist dealing with your child complete an
additional medical form Dom Care 3 available on www.gov.ie, from your local Intreo Centre,
Social Welfare Office or Citizens Information Centre. The complete form will detail your child’s
conditions and any specific care needs the child might have as a result of their disability and will
assist the Department’s Medical Assessor in forming an opinion on eligibility.
If you need any help to complete this form, please contact your local Intreo Centre, Social Welfare
Office or Citizens Information Centre. For more information, *The definitions used for terms such
as severe or substantial in this qualifying condition are detailed in the DCA Medical Guidelines
used by the Department is assessing For more information, visit www.gov.ie.
Application form for
Domiciliary Care Allowance
Dom Care 1
Social Welfare Services
Data Classification R
To help us in processing your application:
Print letters and numbers clearly.
Use one box for each character (letter or number).
Please see example below.
1234567T
M U R P H Y
M A U R E E N
M C D E R M O T T
1 N E W S T R E E T
O L D T O W N
D O N E G A L T O W N
D O N E G A L
Eircode or Postcode
2 8 0 2 1 9 7 0
B O X
O N E C H A R A C T E R P E R
O N E N U M B E R P E R B O X
1. Your PPS Number:
3. Surname:
7. Your date of birth:
4. First name(s):
F 9 4 K O K 1
D D M M Y Y Y Y
Mr. Mrs. Ms. Other
2. Title: (insert an X or
specify)
6. Birth surname:
5. Your first name as it
appears on your birth
certificate:
9. Your telephone number:
10. Your email address:
Contact Details
8. Your address:
X
M A R Y
M A I R E
K E L L Y
SAMPLE
How To Full This Form
County

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