Maternity Leave Credits Application Form

• Published date: 05 July 2021
• Issuer: Department of Social Protection

Maternity Benefit

To be completed by your employer when you return to work.

Employer, please note: Additional unpaid maternity leave

must start immediately after paid Maternity Benefit, that

is after Maternity Benefit paid by the department, and is for

maximum period of 16 weeks

.

We certify that the above employee has taken unpaid maternity

leave as follows, do not includ

e the date your employee was

getting Maternity Benefit:

Application for maternity leave credits

Name:

Address:

PPS Number:

Telephone No:

From: To:

Total number of weeks of unpaid maternity leave taken:

Signed by or for employer

Signature not block letters.

Employer’s official

stamp

Position in company or organisation

Date:

Employer’s registered No:

Telephone No:

Send the completed form to:

Maternity Benefit Section, Department of Social Protection,

McCarter’s Road, Buncrana, Co. Donegal, F93 CH79.

Data Protection Statement

The Department of Social Protection administers Ireland’s social protection system.

Customers are required to provide personal data to determine eligibility for relevant

payments and benefits. Personal data may be exchanged with other government

departments and agencies where provided for by law. Our data protection policy is

available at www.gov.ie/dsp/privacystatement or in hard copy.

00K 07-21 Edition: July 2021

Explanations and terms used in this form are intended as a guide only and are not a legal

interpretation.