Application form for
COVID Pandemic Unemployment Payment
Data Classification R
Social Welfare Services
COVID-UP
This is an emergency payment
Please make a full jobseekers application form (UP1) within the next six weeks, form are
available on www.gov.ie/deasp. This Payment will only last for a maximum of SIX
weeks.
First Name
oooooooooooo
Surname
ooooooooooo
PPS No
oooooooooo
Mothers Birth Surname
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Address
ooooooooooooooooooooooooooo
County
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Phone Number
ooooooooooo
E-mail address:
ooooooooooooooooooooooooo
Date of Birth
oo
/
oo
/
oooo
Employer name, address and phone no. _______________________________________________
Last day worked/paid to:
oo
/
oo
/2020 Why did this job nish? ______________________
Are you still working casually, part-time etc.? Yes
o
No
o
Are you in receipt of another weekly Social Welfare payment ? Yes
o
No
o
Bank Account Details
Bank Name
ooooooooooooooo
Account Name
ooooooooooooooo
BIC
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IBAN
ooooooooooooooo
Please keep checking your Bank Account as payment may issue in advance of notication.
DECLARATION BY CLAIMANT
I declare that I am not being paid by my employer at the moment.
I state that I will inform the Department if there are any changes in my circumstances which may
aect my entitlement to payment.
I know that it is an oence to provide false information or to withhold information to qualify for this
payment.
Signed: ____________________________________ Date: _____/_____/2020
Claimant’s Signature
Post this form back to PO Box 12896, Dublin 1 or drop into your local Intreo Centre/Social Welfare Branch Ofce
Data Protection Statement
The Department of Employment Affairs and Social Protection administers Ireland’s social protection system. Customers
are required to provide personal data to determine eligibility for relevant payments/benefits. Personal data may be ex-
changed with other Government Departments/Agencies where provided for by law. Our data protection policy is available
at
www.gov.ie/privacystatement
or in hard copy.
.
For Ocial Use Only
I award a payment to this customer -
Signature of DP/DO: _____________________________ Date: _____/_____/2020
Name of DP/DO: ________________________________
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