Supplementary Welfare Allowance Assistance towards Funeral Expenses Application Form (SWA5)

• Published date: 26 April 2021
• Issuer: Department of Social Protection

Page 1

Application form for

Supplementary Welfare Allowance

Assistance Towards Funeral Expenses

Social Welfare Services

SWA 5

Data Classification R

2. Title, insert an X or specify:

Your detailsPart 1

1. PPS Number:

Mr Mrs Ms Other

3. Surname:

4. First names:

5. First name as it appears on

your birth certificate:

6. Birth surname, if different:

7. Mother’s birth surname:

8. Date of birth:

D D M M Y Y Y Y

Yes No

9. Are you the deceased’s next of kin?

If no, please state your

relationship to the deceased:

10. Address:

Eircode

County

12. Email address:

L A N D L I N E

M O B I L E11. Telephone numbers:

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.

Signature, not capital letters.

Date:

D D M M Y Y Y Y

2 0

Declaration

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

a prison term or both.