Social Welfare Services

SWA1
Application form for Data Classification R

Supplementary Welfare Allowance

What is Supplementary Welfare Allowance (SWA)?

This form will allow you to apply for a payment under the Supplementary Welfare Allowance
scheme. There are a number of different types of payments you might receive. The department
will make the decision on the type of payment based on the information you supply on this form.
A SWA payment can be made weekly or monthly or you may get a once off payment.

You can apply for Supplementary Welfare Allowance if you:

• Are living in Ireland; and
• Need help to provide for your needs and those of your family.

Some examples of payments are:

• Weekly payment while waiting on another payment, or if you don’t qualify for another
payment;
• Once-off payment to meet the costs of buying furniture or household items when setting up a
home for the first time;
• Cost of travel to visit relatives in hospital or prison;
• Financial assistance with the funeral costs of a relative; or
• Payment to meet immediate needs in case of an emergency event, for example a housefire.

How to complete this application form:

• Write with a black ball point pen.
• Use BLOCK LETTERS and place an X in the relevant boxes.
• Answer all the questions that apply to you, leave the others blank.
• When the form is completed, sign the declaration in Part 5.
You may be asked for additional information separately and to provide written evidence to support
your application.
If you need any help to fill in this form, please contact any Citizen Information Centre or your local
Intreo Centre or Branch Office.
For more information, visit www.gov.ie
 How to fill in first page of this form
To help us with your application:
1. Please print letters and numbers clearly;
2. Use one box for each character, letter or number; and
3. Leave Boxes blank if they do not apply to you.
1. Please tell us why you are applying for a payment and give any additional information
which you feel may be important for your application:
Why you are applying for Supplementary Welfare Allowance and any other information
for application.

2. Your PPS Number: 1 2 3 4 5 6 7 T

3. Title: (insert an X or Mr Mrs X Ms Other
specify)
4. Surname: M U R P H Y

5. First name(s): M A U R E E N

6. Your birth surname: S M I T H

7. Your date of birth: 2 8 0 2 1 9 7 0
D D M M Y Y Y Y
Contact Details
8. Your address: 1 N E W S T R E E T
O L D T O W N
D O N E G A L T O W N
County D O N E G A L
Eircode A 6 5 F 4 E 2
9. Your telephone number: O N E N U M B E R P E R B O X

10. Your email address: O N E C H A R A C T E R P E R

B O X
11. Are you? X Single Separated In a Civil Partnership
Married Divorced A surviving Civil Partner
Widowed Cohabiting A former Civil Partner
(you were in a Civil Partnership that

SAMPLE
has since been dissolved)
 For Official Use Only Social Welfare Services
Date received
SWA1
Application form for By whom
Data Classification R

Supplementary Welfare Allowance

Part 1 Your own details

1. Please tell us why you are applying for a payment and give any additional information
which you feel may be important for your application:
For Office
Use

BASI o

ENP o
SUPP o

UNP o

HRC
Satisfied or N/A o

HRC1 issued o

2. Your PPS Number:

3. Title: (insert an X or Mr Mrs Ms Other
specify)
4. Surname:

5. First name(s):

6. Your birth surname:

7. Your date of birth:
D D M M Y Y Y Y
Contact Details
8. Your address:

County
Eircode
9. Your telephone number:
10. Your email address:

11. Are you? Single Separated In a Civil Partnership

Married Divorced A surviving Civil Partner
Widowed Cohabiting A former Civil Partner
(you were in a Civil Partnership that
Page 1 has since been dissolved)
Part 1 continued Your own details
12. Do you have a social security number from another country:
Yes No
If Yes, please state:
Social security number:
13. Are you in full time Yes No
education:
14. Are you employed: Yes No
If Yes, please state:
Your weekly income
from employment: € , .
Total number of hours
worked a week:
Your occupation:

Your employer’s name:

Your employer’s address

If No, please state:

Date you were last
employed:
D D M M Y Y Y Y
15. If you are self-employed, including farming, please state:
Type of business or trade:
Your profit over the
last year: € , .
16. If you are getting or have applied for any other payment(s) for example from social welfare,
the Health Service Executive, an occupational pension, a pension or allowance from another
country, maintenance or any other income, please give details:
Name of payment(s):

Amount per week: € , .

17. Do you have savings or accounts in a bank, post office, building society, credit union or any
other financial institution in Ireland or another country?
Do you have any investment accounts including stocks, bonds or shares in Ireland or any
other country?
Yes No
If Yes, please state:
The current amount: € , .
Where it is invested:

Page 2
Part 1 continued Your own details
18. Do you own or share in the ownership of any property, including land, in Ireland or in another
country other than the house where you live?
Yes No
If Yes, please state:
Property or land address:

Its value: € , ,
Use of property or
land:
Note: Please use a blank sheet for additional information for questions 16-18 if needed.
19. How much are you, your spouse,
Your Spouse, Partner
partner or cohabitant paying weekly on:
You or Cohabitant
House Rent or Mortgage € . € .
Maintenance payments to another person € . € .
Loans, for example from banks, credit
union. € . € .
Other € . € .
Please specify:

Part 2 Your spouse’s, partner’s or cohabitant’s details

20. Their PPS Number:
21. Title: (insert an X or Mr Mrs Ms Other
specify)
22. Their surname:
23. Their first name(s):

24. Their birth surname:

25. Their date of birth:

D D M M Y Y Y Y
26. Do they have a social security number from another country:
Yes No
If Yes, please state:
Social security number:
27. Are they employed? Yes No
If Yes, please state:
Their weekly income
from employment: € , .
Their occupation:
Their employer’s name:

Their employer’s address:

Page 3
 Part 2 continued Your spouse’s, partner’s or cohabitant’s details
28. Are they self-employed, including farming, please state:
Type of business or trade:
Their profit over the
last year: € , .
29. Do they have savings or accounts in a bank, post office, building society, credit union or any
other financial institution in Ireland or another country?
Do they have any investment accounts including stocks, bonds or shares in Ireland or any
other country?
Yes No
If Yes, please state:
The current amount: € , .
Where it is invested:

30. Do they own or share in the ownership of any property, including land, other than the house you
occupy?
Yes No
If Yes, please state:
Property or land address:

Its value: € , ,
Use of property or land:
Note: Please use a blank sheet for additional information for questions 29 and 30 if needed.
Part 3 Your children’s details
31. Please give details of children under 18 years of age or 18-22 years who are still in full-time
education and are dependent on you:
Does this
Relationship child live
First Name Surname Date of Birth PPS Number
to you with you?
YES or NO

Note: Please use a blank sheet for additional children if needed.

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Part 4 Payment details
32. Please tick which payment method you would prefer and fill in details below.
1. Electronic Fund Transfer to a Bank Account
2. Payment at a Post Office
3. Nominated Payment
Note: Final decision on payment method is a matter for the department.

Financial Institution
Note: You will find the details requested below printed on statements from your financial institution.

Name of financial institution:

Address of financial
institution:

County Eircode

Bank Identifier Code (BIC):

International Bank Account
Number (IBAN):

Name(s) of account holder(s):

Post Office
Post Office address:

County Eircode

Nominated Payment
Nominated Payment: Your payment can be made to a third party with your consent.
If you wish your payment to go to another person or company please provide the following details:
Name of financial institution:

Bank Identifier Code (BIC):

International Bank Account
Number (IBAN):

Name of account holder:

By Cheque payment to:

Name:
Address:

Page 5
Part 5 Declaration
I declare that the information given by me on this form is truthful and complete. I understand that if any
of the information I provide is untrue or misleading or if I fail to disclose any relevant information,
that I will be required to repay any payment I receive from the department and that I may be
prosecuted. I undertake to immediately advise the department of any change in my circumstances
which may affect my continued entitlement.

Date: 2 0
D D M M Y Y Y Y
Signature (not block letters)

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

Part 6 Checklist

• Photographic ID: If you have a Public Service Card (PSC), photographic ID is not required.
Your passport, driver’s licence or other official photographic ID may be supplied if you do not
have a Public Service Card.
• Did you give as much detail as possible about your application in Part 1?
• Proof of household income: If you or your spouse, civil partner or cohabitant are employed,
please provide a recent payslip (Questions 14 and 27).
• Self-employment: If you or your spouse, civil partner or cohabitant are self-employed, please
provide the profit and loss account for the last 12 months, together with the most recent notice
of assessment from the Office of the Revenue Commissioners (Questions 15 and 28).
• If you answered yes to questions 17 or 29, then please provide a recent statement from the
financial institution.
• Have you included any additional sheets that were needed to answer questions fully?
(Questions 16, 17, 18, 29, 30 and 31)?
• Have you signed the declaration in Part 5?

Send this completed form to:

Return this form to your local Intreo Centre or office administering Supplementary Welfare
Allowance.

Data Protection Statement

The Department of Social Protection administers Ireland’s social protection system. Customers
are required to provide personal data to determine eligibility for relevant payments and benefits.
Personal data may be exchanged with other government departments and agencies where provided
for by law. Our data protection policy is available at www.gov.ie/dsp/privacystatement or in hard
copy.

Explanations and terms used in this form are intended as a guide only and are not a legal interpretation.
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25K 11-20 Edition: November 2020