Recovery of Benefits and Assistance (RBA) Scheme Application Form (RBA01)

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

Signature (not block letters)

Oifig Sheirbhísí Leasa Shóisialaigh,

An Rannóg Aisghabhála Sochar

agus Cúnamh,

Bosca O.P. 12515,

Baile Átha Cliath 1,

D01 WY03.



: (01) 817 2660

Social Welfare Services Office,

Recovery of Benefits and

Assistance Section,

P.O. Box 12515,

Dublin 1,

D01 WY03.

*Reference no.:

*Name of compensator:

*Address:

Country:

Post Code:

Email:

Telephone: Landline:

Mobile:

Reference no.:

*Name of case manager:

*Address:

Country:

Post Code:

*Email:

*Telephone: Landline:

Mobile:

In accordance with Part 11B of the Social Welfare C onsolidation Act 2005, I/we wish to apply for a statement of recoverable benefits in r espect of

the injured person named overleaf who has made a personal injury claim for compensation based on the injury & incident date specified overleaf.

*Requestor: Date: / /

Compensator

Request for a statement of Recoverable Benefits

Please use a BLACK ballpoint pen and BLOCK capitals when completing this form

*Mandatory

Contact details of Compensator’s Case manager (agent/legal representative)

Declaration