Living Alone Increase Application Form (LA1)

Published date26 April 2021
IssuerDepartment of Social Protection
1. Your PPS No:
3. Surname:
5. Your date of birth:
4. First name(s):
Mr. Mrs. Ms. Other
2. Title: (insert an ‘X’ or
specify)
Contact Details
Application form for
Living Alone Increase
Please use BLOCK LETTERS
Please use BLACK INK and complete all questions.
If a question does not apply to you, please leave the answer area blank.
For more information, log on to www.gov.ie.
I declare that all the information I have given on this form is accurate.
I will tell the Department when my means or circumstances change.
Warning: If you make a false statement or withhold information, you may be prosecuted leading to a
fine, a prison term or both.
Declaration
D D M M Y Y Y Y
Signature (not block letters)
Date:
D D M M Y Y Y Y
Your own detailsPart 1
7. Your telephone number:
L A N D L I N E
M O B I L E
8. Your email address:
6. Your address:
Data Classification
Confidential
Social Welfare Services

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