Widowed or Surviving Civil Partner Grant Application Form (WPG1)

• Published date: 06 July 2021
• Issuer: Department of Social Protection

1. Your PPS Number:

3. Surname:

7. Your date of birth:

4. First name(s):

Mr. Mrs. Ms. Other

2. Title: (insert an X or

specify)

5. Your birth surname:

9. Your telephone number:

Contact Details

• 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.

6. Your mother’s birth

surname:

I declare that all the information I have given on this form is accurate.

Declaration

MOBILE

D D M M Y Y Y Y

8. Your address:

10 .Your email address:

Signature (not block letters)

Date:

D D M M Y Y Y Y

Your own detailsPart 1

LANDLINE

Application form for

Widowed or Surviving Civil

Partner Grant

WPG 1

Social Welfare Services

Data Classification R

2 0