Paternity Benefit: Medical Certificate Application Form (PB3)

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

Medical Certicate for

Paternity Benet Data Classication R

Social Welfare Services

PB 3

Page 1

If you make any alterations after you complete the form, you must initial and date them

otherwise the information supplied cannot be accepted.

Mother’s PPS Number:

Mother’s name:

If you are self-employed, a doctor must complete this form to certify the expected

due date of your baby (or the baby’s date of birth). This is required to conrm that

you are entitled to paternity leave.

D D M M Y Y Y Y

DEASP panel number:

Doctor’s name:

Doctor’s Signature (not block letters)

Doctor’s official stamp

IMC number:

Your details

is expected to give

birth on:

D D M M Y Y Y Y

Date of Certication:

Your PPS Number:

Your name:

Details of birth (to be completed by doctor)

I certify that:

D D M M Y Y Y Y

gave birth on:

or