Employee Retention Grant Claim Form

• Published date: 10 May 2021
• Issuer: Department of Social Protection

Amended: 21/11/18 (Final version)

Employee Retention Grant Scheme

KEEPING PEOPLE IN WORK ERG Claim Form

Please refer to the General Conditions before completing this form.

YOUR DETAILS

Please type or complete this form in BLOCK CAPITALS

Company Name: _____________________________________ Tel: ___________________

Tax No/VAT No: _____________________________________ Fax: ___________________

Address: ___________________________________________________________________

__________________________________________________________________________

Email: _____________________________________________________________________

Name of Employee: ________________________________ PPS No: __________________

Stage of Employee Retention Grant Scheme for which payment is now being sought:

(Please tick as appropriate) Stage 1 Stage 2

COSTS FOR WHICH PAYMENT IS BEING SOUGHT

Stage 1 Costs (Development of the Retention Strategy) Cost € Amount Claimed

Occupational Capacity Evaluation:

Workplace/Job Assessment:

Development of the Individual Retention Strategy:

Other Costs: (Details must be provided)

TOTAL (All relevant invoices/receipts must be attached):

Please attach the following and check the box √ to indicate that each document has been included

DSP

Use

Only

Copy of written Retention Strategy:

Invoices/receipts of payment(s) to Specialist(s) [‘Claim Requirements’ (iii)(a)]:

Copy of relevant bank statement [‘Claim Requirements’ (iii)(b)]:

Copy of bank draft (if applicable) [‘Claim Requirements’ (iii)(c)]:

Current Tax Clearance Cert (TCC)/Electronic Tax Clearance Access No (TCAN) for Employer

if not previously submitted:

Current Tax Clearance Cert(s) (TCC)/Electronic Tax Clearance Access No(s) (TCANs) for

Specialist(s) or their employer(s), if not previously submitted: