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
If Faxing please ensure Employee’s Name and Personnel Number are included on each page of the form
Name ____________________________ Personnel No._________________
HR 107(b) Oct 2013 Page 2 of 3 05/12/2013
Section 6. Bank Details (confirm details of account you wish your benefits to be paid
to)
Bank Name Bank Address
Bank Sort Code
Account Number
Bank Identifier
Code (BIC)
International Bank
Account No(IBAN)
Payee Name
Section 7. PRSI Class
Please (
) One
Are you a Full Medical Card Holder
Yes No
Are you a GP Visit Card Holder
Yes No
Note: if you have
answered yes to any of
these questions please
attach supporting
documentation from
Dept Social & Family
Affairs (Social Welfare)
or HSE
Section 8. Declaration by Claimant
I Declare that the above information is accurate and correct on the date indicated below
Signature Date
Name (print)
Contact Tel No
Section 9. Declaration by Legal Personal Representative
I Declare that the above information is accurate and correct in respect of the above named on the
date indicated below
Relationship to Claimant Date
Signature
Contact Tel No
Name (print)
E Mail address
Registered Number
Office Stamp
Section 10. To be completed by Pensions Management
System updated by Date
Personnel Number of Deceased Employee / Pensioner
Personnel Number Created for this claimant
Review Date (If applicable)
Deceased Employee/Pensioner removed form payroll
Yes No
HR 107 (b) Appendix 1
To Pensions Payroll Officer
HR National Shared Services
Áras Sláinte Chluainín
Manorhamilton
Co. Leitrim
Local Government Spouses & Children Pension Scheme
This is to Certify that:
Surname First Name
Street Address
Town/City
County Post Code Country
1 (a) Is expected to continue his/her studies/training at:
Until (End of academic year)
(b) If in receipt of training allowance, please specify amount of weekly allowance
2 Has ceased full-time studies/training with effect from:
Last date of
education/training/or examinations, whichever is
later
Signed
Name (print)
Tel No:
Date
School /College/training Centre Stamp
HR 107(b) Oct 2013 Page 3 of 3 05/12/2013
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