Form HK1
Claim for an Allowance for Employing a Carer
If you, your spouse, civil partner or a relative is incapacitated by reason of physical or mental inrmity and you employ a
person to care for the incapacitated relative you may claim this allowance.
Relative’s Details
Name of incapacitated
relative
Relationship
to you
Date incapacity
arose
Nature of
the incapacity
Cost of employing the carer
Please give details of the cost incurred by you of employing the carer stated above:
Net cost, after any payments from the Health Service Executive, etc.
Percentage of carer costs paid by you
Your Personal Details
Name
PPSN
Carer’s Details (if employed directly by you)
Name of carer
PPSN
If provided by or through an agency or other commercial entity
Employer PAYE
Registration No.
Name of
organisation
Date employment
commenced
If you wish to have any refund paid directly to your bank account, please supply your bank account details.
Single Euro Payments Area (SEPA)
Bank account numbers and sort codes have been replaced by International Bank Account Numbers (IBAN) and Bank
Identier Codes (BIC). These numbers are generally available on your bank account statements. Further information
on SEPA can be found on www.revenue.ie.
It is not possible to make a refund directly to a foreign bank account that is not a member of SEPA.
International Bank Account Number (IBAN)
(Maximum 34 characters)
Bank Identier Code (BIC) (Maximum 11 characters)
Note: Any subsequent Revenue refunds will be made to this bank account unless otherwise notied.
Refunds
Declaration which MUST be signed
I declare that all the particulars on this form are correct to the best of my knowledge and belief.
Signature Date
E-mail
Phone No.
DDMMYYYY
DDMMYYYY
, 0 0€ .
%
.
DDMMYYYY
