Pension Dependants Application Form – HR107 (b)
Th
is form is to be used when you are making application for payment of Dependants Pension Benefits. It is
important that you complete this form correctly and forward all requested documentation to Pensions
Management as soon as practicable. One form to be completed in respect of each claimant. Please complete in
Block Capitals/Tick appropriate boxes.
HR 107(b) Oct 2013 Page 1 of 3 05/12/2013
Section 1. To Be Completed by Claimant or their representative
Name of Deceased Employee/Pensioner
His / Her Date of Birth
His / Her Date of Death
Section 2. Personal Details of Claimant
Surname First Name
PPS No
Date of
Birth
Section 3. Relationship to Deceased Employee / Pensioner
Spouse Child/ Dependant
If you are the spouse of the deceased employee/ Pensioner please go to section 6
Section 4. Dependant Child Details
This application is in respect of a child under age 16 Yes No
This application is in respect of a child aged 16 – 22 who
is receiving full time education
Yes No
If Yes please ensure
appendix A is completed.
This application is in respect of a disabled child/Adult
dependant
Yes No
If Yes please attach
Medical officers
Confirmation
Section 5. Address (for receipt of written communications from the HSE)
Street Address
Town/City
County Post Code Country
Phone No:
Mo
bile Phone
No:
Please ensure that you advise Pensions Management of any changes to your address
