hrc1

Application form for

Habitual Residence Condition

D D M M Y Y Y Y

Thank you for your application for on

. However, we need more information to decide whetheryou are habitually resident in the Republic of Ireland. Please answer the questions in this form to help us decide this issue.

How to complete application form for Habitual Residence Condition.

• Please use this page as a guide to filling in this form.

• Please use blaCk ball point pen.

• Please use BLOCK LETTERS and place an X in the relevant boxes.

• Please answer all questions that apply to you.

• You need a Personal Public Service Number (PPS No.) before you apply.

applicant:

Fill in all Parts. When form is completed, sign declaration in Part 1.

If you fail to answer all questions, your application will be delayed.

If you need any help to complete this form, please contact your local Social WelfareOffice or Citizens Information Centre.

For more information, log on to www.welfare.ie.

Data Classification R

Social Welfare Services

HRC 1

How to fill in first page of this form

To help us in processing your application:

• Print letters and numbers clearly.

• Use one box for each character (letter or number).

Please see example below.

SAMPLE

1 2 3 4 5 6 7 T

M U R P H Y

M A U R E E N

M C D E R M O T T

1 N E W S T R E E T

O L D T O W N

C O D O N E G A L

M O B I L E

L A N D L I N E

0 8 6 1 2 3 4 5 6 7

0 1 7 0 4 3 0 0 0

2 8 0 2 1 9 7 0

M M U R P H Y @ W E L F A R E . I E

1. Your PPS No.:

3. Surname:

8. Your date of birth:

4. First name(s):

D D M M Y Y Y Y

Mr. Mrs. Ms. Other2. Title: (insert an ‘X’ orspecify)

6. Birth surname:

5. Your first name as itappears on your birthcertificate:

10.Your telephone number:

11.Your email address:

Contact Details

9. Your address:

X

M A R Y

7. Your mother’s birthsurname:

K E L L Y

Part 1 Your own details

1. Your PPS No.:

3. Surname:

8. Your date of birth:

4. First name(s):

2. Title: (insert an ‘X’ orspecify)

6. Birth surname:

5. Your first name as itappears on your birthcertificate:

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

Signature (not block letters)

Date:

D D M M Y Y Y Y

2 0

10.Your telephone number:M O B I L E

L A N D L I N E

11.Your email address:

9. Your address:

Declaration

7. Your mother’s birthsurname:

D D M M Y Y Y Y

Contact Details

Warning: If you make a false statement or withhold information, you may beprosecuted leading to a fine, a prison term or both.

Application form for

Habitual Residence Condition

Mr. Mrs. Ms. Other

Data Classification R

Social Welfare Services

HRC 1

Your own detailsPart 1 continued

14.Country were you bornin?

15.Your nationality?

The European Economic Area (EEA) comprises the Member States of the European Uniontogether with Iceland, Norway and Liechtenstein.

16.If you are not an EEA national, do you hold a current: Irish Residence Permit(Stamp 4)?Irish Employment Permit(Stamp 1)?Student Visa (Stamp 1A,Stamp 2, Stamp 2A,Stamp 3)?If ‘Yes’ to either question, please enclose your original permit and your original letter fromDepartment of Justice, which sets out the reasons you have been granted permission toreside in the Republic of Ireland. If ‘No’ to either question, have you applied for permit renewal?

Please give further details as to your residence and/or employment status, and enclose anyrelevant documentation (e.g. your original most recent permit and a copy of your renewalapplication).

17.Do you have a current GNIB Card?

If ‘Yes’, please state:Your GNIB Number:

Yes No

Yes No

Yes No

Yes No

Yes No

12.Are you? Single

Married

Separated

Divorced

Widowed

Cohabiting

In a Civil Partnership

A surviving Civil Partner

A former Civil Partner(you were in a Civil Partnershipthat has since been dissolved)

If you are:Married or entered into a civil partnership, from what date?

D D M M Y Y Y Y

Cohabiting, from what date? D D M M Y Y Y Y

Separated, divorced or civil partnership dissolved, from what date?

D D M M Y Y Y YA copy of your divorce or separation papers must be submittedwith your claim.

13.How well do you speakEnglish?

Very Well Well

Not Well Not at all


20.How did you support yourself when you lived in the Republic of Ireland?

22.How did you support yourself while you were abroad?

21.Why did you leave the Republic of Ireland?

23.When did you come to live or return to live in the Republic of Ireland?

D D M M Y Y Y Y

24.Why did you come or return to the Republic of Ireland?

If ‘Other’, please give details:

25.How do you plan to support yourself in the Republic of Ireland? (Include details of funds youcan access)

19.Dates of previous residence:

From:

To:D D M M Y Y Y Y

18.Have you lived in the Republic of Ireland previously?

If ‘Yes’, please complete fully the remainder of this section.If ‘No’, please go to question 23.

Yes No

Study Work Family Other


27.Please give details of each country, outside the Republic of Ireland, that you have lived in.

Country:Dates you lived there:

Country 1

From:

To:D D M M Y Y Y Y

Why did you live there?


Country 2

From:

To:D D M M Y Y Y Y



Country 3

From:

To:D D M M Y Y Y Y


Yes No

26.Have you lived in the Republic of Ireland continuously since the date you came to live here orreturned to live here?

If ‘Yes’, please provide proof of residency, for example, a tenancy agreement.


28.Do you own or have you ever owned property in the Republic of Ireland?

If ‘Yes’, please state:Address of the property:

Are you living in theproperty?Is the property rented?Have you sold theproperty?


Country 4

From:

To:D D M M Y Y Y Y


29.Do you own or have you ever owned any kind of property, lands or business abroad?

If ‘Yes’, please state:The address:

Did you ever live there?

Is it rented?

Was it sold?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Note: A separate sheet of paper can be used for more details if needed.


31.How long do you plan to stay in the Republic of Ireland?

If ‘Over 5 years’, please give details:

30.Do you have bank accounts in other countries?

If ‘Yes’, please give details:Yes No

0-1 year 1-2 years 3-5 years Over 5 years

32.Do you belong to any professional bodies, community groups, social or sports organisations inthe Republic of Ireland?

If ‘Yes’, please give details:Yes No

33.Have you ever been imprisoned in the Republic of Ireland?Yes No

If ‘Yes’, please give details:

Your work detailsPart 2 continued

Employer’s name:

Employer’s address:

Dates you worked there:Job title:

From:

To:D D M M Y Y Y Y

Employer 1

37.Please give details of all your previous employments in the Republic of Ireland, starting withyour first employer.

34.Did you arrange employment prior to coming to the Republic of Ireland?


35.Have you always worked since coming to the Republic of Ireland?Yes No

Yes No

36.Are you employed at present in the Republic of Ireland?

If ‘Yes’, please state:Employer’s name:


D D M M Y Y Y YWhen employment started:

Is your employment:Have you a written contract of employment?

How long is the job likely tolast?

D D M M Y Y Y Y

Full-time Part-time

Yes No

Yes No

Your work detailsPart 2 continued

If yes, please state:

Dates of self-employment:From:

To:D D M M Y Y Y Y

40.Were you ever self-employed in the Republic of Ireland?

Type of work you do:

41.If you have never worked in the Republic of Ireland, have you looked for work since cominghere?


Yes No

Yes No

Type of work you do:

D D M M Y Y Y Y

Date you started self-employment:

39.Are you self-employed at present in the Republic of Ireland?

If ‘Yes’, please state:Yes No

38.If you worked in the United Kingdom please give your United Kingdom social servicesnumber:

Employer’s name:


Dates you worked there:Job title:

From:

To:D D M M Y Y Y Y

Employer 2


Part 3

42.Their PPS No.:

44.Their surname:

48.Their date of birth:

45.Their first name(s):

43.Title: (insert an ‘X’ orspecify)

46.Their birth surname:

47.Their mother’s birthsurname:

D D M M Y Y Y Y

50.Do they live in the Republic of Ireland with you?

If ‘Yes’, please state:Date their current stay inthe Republic of Irelandbegan: D D M M Y Y Y Y

If ‘No’, please state where they are and any plans you have made for them to join you:

49.Their nationality:

Mr. Mrs. Ms. Other

Yes No

Your spouse’s, civil partner’s or cohabitant’s details

51.Did they arrange work prior to coming to the Republic of Ireland?


52.Have they always worked since coming to the Republic of Ireland?

53.Are they employed at present in the Republic of Ireland?

If ‘Yes’, please state:Employer’s name:


D D M M Y Y Y YWhen employment started:

Is their employment:Have they a written contract of employment?

How long is the job likely tolast?

D D M M Y Y Y Y

Yes No

Full-time Part-time

Yes No

Yes No

Yes No

Your spouse’s, civil partner’s or cohabitant’swork and claim details

Part 4

Details of your qualified child(ren)Part 5

55.Do your children or other dependants live in the Republic of Ireland with you?

If ‘No’, please state where they are and any plans you have made for them to join you:

Surname:

First name(s):

D D M M Y Y Y YDate of birth:

Child or dependant 3

Yes No


54.Do you have children orother dependants?If ‘Yes’, please state child or dependant’s:

Surname:

First name(s):



Yes No

Surname:

First name(s):



D D M M Y Y Y Y

Child’s surname:

Child’s name:

Start date:

Name of school:

Address of school:

Child 3

56.Are your children in school in the Republic of Ireland?

If ‘Yes’, please state:

D D M M Y Y Y Y

Child’s surname:

Child’s name:

Start date:

Name of school:

Address of school:

Child 1

D D M M Y Y Y Y

Child’s surname:

Child’s name:

Start date:

Name of school:

Address of school:

Child 2


Yes No

Details of your qualified child(ren)Part 5 continued

Details of other family membersPart 6

Their PPS No.:

Their surname:

Their first name(s):

Their date of birth:

D D M M Y Y Y Y

Their address:

Their relationship to you:

Date they came to the Republic of Ireland:

D D M M Y Y Y Y

Person 2

57.Does any of your close family, for example parent, brother, sister or child, live in the Republicof Ireland?

Their PPS No.:

Their surname:




D D M M Y Y Y Y

Their address:



D D M M Y Y Y Y

Person 1

Yes No

Details of other family membersPart 6 continued

Their PPS No.:

Their surname:



D D M M Y Y Y Y

Their address:



D D M M Y Y Y Y

Person 4

Their PPS No.:

Their surname:



D D M M Y Y Y Y

Their address:



D D M M Y Y Y Y

Person 3



Their PPS No.:

Their surname:



D D M M Y Y Y Y

Their address:



D D M M Y Y Y Y

Person 5

58.Does any of your close family, for example parent, brother, sister or child, live outside theRepublic of Ireland?

Their surname:



Their address:


Person 1

Yes No

Their surname:


Their address:


Person 2

Their surname:


Their address:


Person 3



150K 06-11 Edition: June 2011

Data Protection and Freedom of Information

We, the Department of Social Protection, will treat all information and personal data you giveas confidential. We will only disclose it to other people or bodies according to the law.

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

Your residence permit or renewal application

Your work permit

Your GNIB documents

If born, married or entered into a civil partnership or civil union outside the Republic of Ireland:

Your birth certificate

Your spouse’s, civil partner’s or cohabitant’s birth certificate

Your marriage certificate or civil partnership or civil union registration certificate

Your divorce, dissolution of civil partnership or separation documents

Only original certificates will be accepted

Please remember to sign the declaration in Part 1.

ChecklistPart 7

Have you enclosed the following?

hrc1

Documents

Transcript of hrc1