Household Benefits Package Application Form (HB1)

• Published date: 01 April 2021
• Issuer: Department of Social Protection

4558149477

45581494774558149477

4558149477

1. Your PPS Number:

3. Surname:

6. Your date of birth:

4. First name(s):

5. Your birth surname:

Contact Details

Application form for

Household Benefits Package

D D M M Y Y Y Y

8. Your address:

10. Your email address:

Signature (not block letters)

Date:

D D M M Y Y Y Y

Declaration

Warning: If you make a false statement or withhold information, you may be prosecuted leading to a

fine, a prison term or both.

I declare that the information given by me on this form is truthful and complete. I understand that if any of the

information I provide is untrue or misleading or if I fail to disclose any relevant information, that I will be required

to repay any payment I receive from the department and that I may be prosecuted. I undertake to immediately

advise the department of any change in my circumstances which may affect my continued entitlement.

9. Your telephone number:

Part 1 Your own details

Mr Mrs Ms Other

2. Title: (insert an X or

specify)

HB 1

Social Welfare Services

Data Classification R

You need a Personal Public Service Number (PPS Number) before you apply.

• Please use BLACK ball point pen.

• Please use BLOCK LETTERS and place an X in the relevant boxes.

• Please answer all questions.

For more information, please visit www.gov.ie

Page 1

County Postcode

2 0

12345678

7. Your mother’s birth surname:

Mobile

Landline