Social Welfare Services

Application form for HRC 1

Data Classification R

Habitual Residence Condition

Thank you for your application for

on D D M M 2 0 Y Y
However, we need more information to decide if you are habitually resident in the
Republic of Ireland. Please answer the questions in this form to help us decide.

What does Habitual Residence mean?

Being habitually resident means that you are living in the Republic of Ireland and can prove
that you have a close link to the State.

How do I qualify for Habitual Residence?

Factors taken into consideration when deciding if a person is habitually resident in the Republic
of Ireland include:
• If you were born and raised here;
• If you have a right to live here;
• The length of time you have lived here and if you have lived here continuously;
• If you have worked here;
• If you have close family ties or ties with the community here; and
• Your general living situation here.
Time spent outside the Republic of Ireland on short holidays, studying or travelling does not
exclude a person from being regarded as habitually resident

What do I need to complete this form?

• You need a Personal Public Service (PPS) Number before you apply.
How do I complete this application form?
• There is an example on the back of this page that can be used as a guide to fill in this form.
• Write with a black ballpoint pen.
• Use BLOCK LETTERS and place an X in the relevant boxes.
• Answer all the questions as incomplete forms will be returned and this may delay your
application.
• Sign the declaration in Part 1.
How can I get help and further information?
If you need any help to complete this form, please contact your local Intreo Centre, Social
Welfare Office or any Citizens Information Centre. You can find the name and address of your
local Intreo Centre or Social Welfare Office by visiting www.gov.ie/intreo
For more information on the Habitual Residence Condition visit www.gov.ie/hrc
 How to fill in this form

To help us to process your application write letters and numbers clearly and use one box
for each. Please see examples below.

Part 1 Your own details

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

2. Title, insert an ‘X’ or Mr Mrs X Ms Other
specify:
3. Surname: M U R P H Y

4. First names: M A U R E E N
5. Your first name as it M A R Y
appears on your birth
certificate:
6. Birth surname: M C D E R M O T T

7. Your date of birth: 2 8 0 2 1 9 7 0

D D M M Y Y Y Y
8 . Your mother’s birth K E L L Y
surname:

Contact Details
9. 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 C 1 5 A 9 6 V

10. Your telephone numbers: O N E N U M B E R P E R B O X

Mobile
O N E N U M B E R P E R B O X
Landline
11. Your email address: O N E C H A R A C T E R P E R
B O X

SAMPLE
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 Social Welfare Services

Application form for HRC 1

Data Classification R

Habitual Residence Condition

Part 1 Your own details
1. Your PPS Number:
2. Title, insert an ‘X’ or Mr Mrs Ms Other
specify:
3. Surname:

4. First names:
5. Your first name as it
appears on your birth
certificate:
6 . Birth surname:

7. Your date of birth:

D D M M Y Y Y Y
8 . Your mother’s birth
surname:
Contact Details
9. Your address:

County Eircode

10. Your telephone numbers: Mobile

Landline

11. Your email address:

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.
Page 1
Part 1 continued Your own details
12. Are you? Single Cohabiting
Married In a Civil Partnership
Separated A surviving Civil Partner
Divorced A former Civil Partner

Widowed (you were in a Civil Partnership

that has since been dissolved)
13. If you are:
Married or entered into
a civil partnership, from
what date? D D M M Y Y Y Y

Cohabiting, from what date?

D D M M Y Y Y Y
Separated, divorced or
civil partnership dissolved,
from what date? D D M M Y Y Y Y

Note: A copy of your divorce or separation papers must be submitted with your claim.

If your spouse, civil partner or cohabitant died, what was their date of death?

D D M M Y Y Y Y
14. Would you like an interpreter service to help us process your application?
Yes No
15. Do you have a current Irish Residence Permit (IRP) Card?
Yes No
If yes, please state:
Your IRP Number:

16. What country were you

born in?
17. Your nationality?

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Part 1 continued Your own details
18. If you are not an EEA or UK national, do you hold a current:
Irish Residence Permit? Yes No
Irish Employment Permit? Yes No
Student Visa? Yes No
Note: The European Economic Area (EEA) comprises the Member States of the European
Union together with Iceland, Norway and Liechtenstein.
If you answer yes to any of the three questions above, please enclose your original permit and
your original letter from the Department of Justice which sets out the reasons why you have
been granted permission to reside in the Republic of Ireland.
If you do not have a current or valid permit, have you applied for a permit renewal?
Yes No
Please give further details as to your residency and/or employment status. Please enclose
any relevant documentation, for example, your original most recent permit and a copy of your
renewal application.
Residency outside the Republic of Ireland
19. Please give details of each country, outside the Republic of Ireland, that you have lived in.
Country 1
Country:

Dates: From:

To:
D D M M Y Y Y Y
Your social insurance
number while there:
Did you have the necessary permission to reside in that country?
Yes No
If no, please outline the circumstances of your residency:

How did you support yourself while you lived in that country?

Note: A separate sheet of paper can be used for more details if needed.
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Part 1 continued Your own details
Residency outside the Republic of Ireland continued
Country 2
Country:

Dates: From:

To:
D D M M Y Y Y Y
Your social insurance
number while there:
Did you have the necessary permission to reside in that country?
Yes No
If no, please outline the circumstances of your residency:

How did you support yourself while you lived in that country?

Country 3
Country:

Dates: From:

To:
D D M M Y Y Y Y
Your social insurance
number while there:
Did you have the necessary permission to reside in that country?
Yes No
If no, please outline the circumstances of your residency:

How did you support yourself while you lived in that country?

Page 4
Note: A separate sheet of paper can be used for more details if needed.
Part 1 continued Your own details
Residency outside the Republic of Ireland continued

20. Provide full details of your last address outside the Republic of Ireland.

Address:

Provide the most recent six months bank statements of all accounts held outside the
Republic of Ireland as evidence.
21. Do you own or have you ever owned any kind of property, land, business or capital for example
outside of the Republic of Ireland?
Yes No
If yes, please state:
Type of property, for example, house, apartment or land.

Address of the property:

Please provide evidence of your ownership of this property.

Did you live in the Yes No
property?
Is the property rented? Yes No
If yes, please provide a copy of a rental or tenancy agreement.
Have you sold the Yes No
property?
If yes, please provide evidence of the completion of sale of this property.

Note: A separate sheet of paper can be used for more details if needed.

22. Please give any further information that may assist your application.

Note: A separate sheet of paper can be used for more details if needed.
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Part 1 continued Your own details

Previous residency in the Republic of Ireland

23. Please give details of each period of time that you resided in the Republic of Ireland.
First period of residency
Your address:

County

Eircode

Dates: From:

To:
D D M M Y Y Y Y
Did you have the necessary permission to reside in the Republic of Ireland at that time?
Yes No

If no, how did you support yourself during this period of residency in the Republic of Ireland?

Second period of residency

Your address:

County

Eircode

Dates: From:

To:
D D M M Y Y Y Y
Did you have the necessary permission to reside in the Republic of Ireland at that time?
Yes No

If no, how did you support yourself during this period of residency in the Republic of Ireland?

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Part 1 continued Your own details

Previous residency in the Republic of Ireland continued

24. Please give details of all your previous employments in the Republic of Ireland, starting with
your first employer.
Employer 1

Employer’s name:

Employer’s address:

County

Eircode
Dates you worked there:
From:

To:
D D M M Y Y Y Y
Was your employment: Full-time Part-time
Did you have a written contract of employment?
Yes No
Number of hours worked a
week:
Employer 2

Employer’s name:

Employer’s address:

County

Eircode
Dates you worked there:
From:

To:
D D M M Y Y Y Y
Was your employment: Full-time Part-time
Did you have a written contract of employment?
Yes No
Number of hours worked a
week:
Note: A separate sheet of paper can be used for more details if needed.
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Part 1 continued Your own details

Previous residency in the Republic of Ireland continued

25. Provide full details of your last address in the Republic of Ireland during your previous period of
residency.

Address:

County

Eircode

26. If you previously lived in the Republic of Ireland were you or your partner in receipt of a social
welfare payment or did someone claim for you as a dependent or student on a social welfare
payment?
Yes No

27. Why did you leave the Republic of Ireland?

28. Please provide any other details you feel may be relevant.

Current residency in the Republic of Ireland

29. When did you come to live in the Republic of Ireland?

D D M M Y Y Y Y

30. Why did you decide to live in the Republic of Ireland?

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Part 1 continued Your own details

Current residency in the Republic of Ireland continued

31. Have you lived in the Republic of Ireland continuously since the date you came to live here or
returned to live here?
Yes No
If yes, please provide proof of residency, for example, documents or evidence to show your
continuous residency in the Republic of Ireland such as a rental agreement and/or utility bills.
If no, state when you were absent from and to, and indicate why you left, for example, study or
holidays.
First absence
Dates you were absent:
From:
To:
D D M M Y Y Y Y
Reason you left:

Second absence
Dates you were absent:
From:

To:
D D M M Y Y Y Y

Reason you left:

32. Are you currently working in the Republic of Ireland?

Yes No
If yes, please give details of employment.
Employer’s name:

Employer’s address:

County

Eircode
Date you started working
there:
D D M M Y Y Y Y
Is your employment: Full-time Part-time
Do you have a written contract of employment?
Yes No
Number of hours worked a
week:
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Part 1 continued Your own details

Current residency in the Republic of Ireland continued

33. Did you arrange or seek to find employment in the Republic of Ireland before coming to the
Republic of Ireland?
Yes No

If yes, please give details.

If no, please give details of how you have supported yourself since you came to the Republic of
Ireland?

34. Were you self-employed? Yes No

If yes, please give details including proof the self-employment was registered with the Office of
the Revenue Commissioners.

35. If you never worked in the Republic of Ireland, have you looked for work in the Republic of
Ireland?
Yes No

If yes, please give details.

Page 10
Part 1 continued Your own details

Current residency in the Republic of Ireland continued

36. Have you undertaken any training?

Yes No
Please provide evidence of any training you have done or are currently doing.

37. How long do you plan to stay in the Republic of Ireland?

38. Please outline in full, the reasons for staying in the Republic of Ireland.

39. Please provide any other information that shows your connection to the Republic of Ireland.
For example, if you belong to any professional bodies, community groups, social or sports
organisations in the Republic of Ireland.

40. Please provide details of any substantial change in circumstances since your residency
in the Republic of Ireland.

Page 11
Part 1 continued Your own details

Current residency in the Republic of Ireland continued

41. Do you own or have you ever owned properties, lands or businesses in the Republic of Ireland?
Yes No
If yes, please state:
Type of property, for example, house, apartment or lands:

Address of the property:

County

Eircode

Please provide evidence of your ownership of this property or land.

Are you living in the Yes No
property?
Is the property rented? Yes No

If yes, please provide a copy of a rental or tenancy agreement.

Have you sold the Yes No
property?
If yes, please provide evidence of the completion of sale of this property.

Note: A separate sheet of paper can be used for more details if needed.

42. Do you have any bank accounts in other countries?

Yes No
If yes, please give details:

Note: A separate sheet of paper can be used for more details if needed.

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Part 2 Your spouse’s, civil partner’s or cohabitant’s details
43. Their PPS Number:
44. Title, insert an ‘X’ or Mr Mrs Ms Other
specify:
45. Their surname:

46. Their first names:

47. Their birth surname:

48. Their date of birth:

D D M M Y Y Y Y
49. Their mother’s birth
surname:
50. Their nationality:

51. Do they live in the Republic of Ireland with you?

Yes No
If yes, please state:
Date their current stay in
the Republic of Ireland
began: D D M M Y Y Y Y

If no, please state where they are and any plans you have made for them to join you:

Note: A separate sheet of paper can be used for more details if needed.

52. Did your spouse, civil partner or cohabitant live in the Republic of Ireland previously?
Yes No

If yes, please outline when and the circumstances of their residency including employment and/
or self-employment details.

53. Please give any other relevant information.

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 Your spouse’s, civil partner’s or
Part 3
cohabitant’s work and claim details
54. Did they arrange work prior to coming to the Republic of Ireland?
Yes No
If yes, please give details:

55. Have they always worked since coming to the Republic of Ireland?
Yes No

56. Are they employed at present in the Republic of Ireland?

Yes No
If yes, please state:
Employer’s name:

Employer’s address:

County

Eircode

When employment started:

D D M M Y Y Y Y
Is their employment: Full-time Part-time

Have they a written contract of employment?

Yes No
How long is the job likely
to last?
D D M M Y Y Y Y
57. Are they currently getting a social welfare payment?
Yes No
If yes, please state:
Name of payment:
If no, have they previously got a social welfare payment?
Yes No
If yes, please state:
Name of payment:

Page 14
Part 4 Details of your children
58. Do you wish to claim for children who normally live with you and who are being supported by
you or any other dependants?
Yes No
If yes, please state child’s or dependant’s:
Child or dependant 1

Surname:

First names:

Date of birth:
D D M M Y Y Y Y

Child or dependant 2

Surname:

First names:

Date of birth:
D D M M Y Y Y Y

Note: A separate sheet of paper can be used for more details if needed.

59. Do all of your children or other dependants live in the Republic of Ireland with you?
Yes No

If no, please state where they are and any plans you have made for them to join you:

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Part 4 continued Details of your children
60. Have you children in school in the Republic of Ireland?
Yes No
If yes, how many
children?
Please state:
Child 1
Surname:

First names:

Date of birth:
D D M M Y Y Y Y
Name of school:

Address of school:

County

Eircode

Start date:
D D M M Y Y Y Y

Child 2
Surname:

First names:

Date of birth:
D D M M Y Y Y Y
Name of school:

Address of school:

County

Eircode

Start date:
D D M M Y Y Y Y

Page 16
Part 4 continued Details of your children
Child 3
Surname:

First names:

Date of birth:
D D M M Y Y Y Y
Name of school:

Address of school:

County

Eircode

Start date:
D D M M Y Y Y Y

Child 4
Surname:

First name:

Date of birth:
D D M M Y Y Y Y
Name of school:

Address of school:

County

Eircode

Start date:
D D M M Y Y Y Y

Page 17
Part 4 continued Details of your children
Child 5
Surname:

First names:

Date of birth:
D D M M Y Y Y Y
Name of school:

Address of school:

County

Eircode

Start date:
D D M M Y Y Y Y
Note: A separate sheet of paper can be used for more details if needed.

Part 5 Details of other family members

61. Does any of your close family live in the Republic of Ireland, for example, parent, brother or
sister?
Yes No
If yes, please state:
Person 1
Their PPS Number:

Their surname:

Their first names:

Their date of birth:

D D M M Y Y Y Y
Their address:

County

Eircode

Their relationship to you:

Date they came to the
Republic of Ireland:
D D M M Y Y Y Y
Page 18
Part 5 continued Details of other family members
Person 2
Their PPS Number:

Their surname:

Their first names:

Their date of birth:

D D M M Y Y Y Y
Their address:

County

Eircode

Their relationship to you:

Date they came to the
Republic of Ireland:
D D M M Y Y Y Y

Person 3
Their PPS Number:

Their surname:

Their first names:

Their date of birth:

D D M M Y Y Y Y
Their address:

County

Eircode

Their relationship to you:

Date they came to the
Republic of Ireland:
D D M M Y Y Y Y
Note: A separate sheet of paper can be used for more details if needed.

Page 19
Part 5 continued Details of other family members
62. Does any of your close family, for example parent, brother or sister, live outside the
Republic of Ireland?
Yes No
If yes, please state:
Person 1
Their surname:

Their first names:

Their address:

Their relationship to you:

Person 2
Their surname:

Their first names:

Their address:

Their relationship to you:

Person 3
Their surname:

Their first names:

Their address:

Their relationship to you:

Note: A separate sheet of paper can be used for more details if needed.

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Part 6 Checklist
Have you enclosed the following where applicable?

Your Irish Residence Permit and the letter setting out any conditions to this residence, or the
renewal application for this Residence Permit.
Your Irish Employment Permit.
Your Irish Work Permit.
Your Irish Student Visa.
Bank statements for the last six months for all bank accounts held outside the Republic of
Ireland.
Documentary proof of continuous residency in the Republic of Ireland.
Documentary proof of registration of self-employment in the Republic of Ireland with the Office of
the Revenue Commissioners.
If you were born, married or entered into a civil partnership or civil union outside of the Republic
of Ireland please submit where applicable:
Your birth certificate.
Your spouse’s, civil partner’s or cohabitant’s birth certificate.
Your marriage certificate or civil partnership or civil union registration certificate.
Your divorce, dissolution of civil partnership or separation documents.
Note only original certificates will be accepted

Please remember to sign the Declaration in Part 1.

If you have any difficulty in filling in this form, please contact your local Intreo Centre or Social
Welfare Office or any Citizens Information Centre. You can find the name and address of your local
Intreo Centre or Social Welfare Office by visiting www.gov.ie/intreo

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 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.
20K 07-21 Edition: July 2021

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