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9Please;use;this;page;as;a;guide;to;filling;in;this;form.
9Please;use;blackball;point;pen.
9Please;use;BLOCK;LETTERS;and;place;an;X;in;the;relevant;boxes.
9Please;answer;3that;apply;to;you.
9You;need;a;Personal;Public;Service;Number;6PPS;No.7;before;you;apply.
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If;you;are;an;employee;or;self:employed;fill;in;P3#-3$-3%-3'-3)3and*as;they;
apply;to;you.;When;form;is;completed4;read;P3+and;sign;declaration;in;P3#.
Please;note;photocopies;of;this;declaration;are;not;acceptable.
To;qualify;for;the;maximum;period;of;26;weeks;maternity;leave4;an;employee;
must;take;at;least;2;weeks;before;the;end;of;the;week;in;which;her;baby;is;due.
D.
Please;only;complete;and;stamp;P3(after;the;24
th
week;of;pregnancy.
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Please;only;complete;and;stamp;P3&after;the;24
th
week;of;pregnancy.
It;is;acceptable;to;forecast;your;employee8s;PRSI<contributions;for;any;period;
after;the;24
th
week;of;pregnancy;up;to;the;date;she;starts;maternity;leave.
If;your;employee;has;been;working;for;you;for;less;than;12;months;before;the;
start;of;her;maternity;leave4;please;forward;a;copy;of;her;P45;from;her;previous;
employment.
If;you;need;any;help;to;complete;this;form4;please;contact;Maternity;Benefit;
Section4;your;local;Citizens;Information;Centre4;your;local;Intreo;Centre;or;your;
local;Social;Welfare;Office.
For;more;information4;log;on;to;!!!,!,,
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Submit;this;form;at;least;6;weeks;612;weeks;if;self:employed7;before;you;intend;
to;start;maternity;leave.
Please;do;not;submit;this;form;more;than;16;weeks;before;the;end;of;the;week;in;
which;your;baby;is;due.
Application;form;for
Maternity;Benefit
Data Classification R
Social WelfareServices
MB 10
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How;to;fill;in;first;page;of;this;form
To;help;us;in;processing;your;application5
9
Print;letters;and;numbers;clearly.
9
Use;one;box;for;each;character;6letter;or;number7.
Please;see;example;below.
SAMPLE
Contact;Details
1
2
3
4
5
6
7
T
M
U
R
H
Y
M
A
U
R
E
E
N
M
C
D
E
R
M
O
T
T
2
8
0
2
1
9
7
0
1. Your PPS No.: 
3. Surname:
8. Your date of birth: 
4. First name(s):
  D
M M
 Y  Y  Y
Mr.
Mrs.
Ms.
Other
2. Title: (insert an ‘X’ or
specify)
6. Birth surname:
5. Your first name as it
appears on your birth
certificate
X
M
A
R
Y
7. Your mother’s birth
surname:
K
E
L
L
Y
L A N D L I N E
M O B I L E
N
E
C
H
A
R
A
C
T
R
P
E
R
B
O
X
10.Your telephone number:
11.Your email address:
N
E
N
U
M
B
E
R
E
R
B
O
X
N
E
N
U
M
B
E
R
E
R
B
O
X
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
9.  Your address: 
County
D
O
N
E
G
A
L
Postcode
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Application;form;for
Maternity;Benefit
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1. Your PPS No.: 
3. Surname:
8. Your date of birth: 
4. First name(s):
Mr.
Mrs.
Ms.
Other
2. Title: (insert an ‘X’ or
specify)
6.Birth surname:
5.  Your first name as it
appears on your birth
certificate: 
Original signature only(notblock letters and nophotocopies)
Date:
  D
M M
 Y   Y   Y
2
0
9. Your address: 
Declaration
7. Your mother’s birth
surname:
D   D
M M
 Y  Y  Y
Contact;Details
Data Classification R
Social WelfareServices
MB 10
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. 
I authorise the Department to disclose details of my Maternity Benefit claim to my employer.
10.Your telephone number:
11.Your email address:
M O B I L E
L A N D L I N E
The Department is required, by legislation, to share information with the Office of the Revenue Commissioners.
Warning:If you make a false statement or withhold information, you may be prosecuted leading
to a fine, a prison term or both.
County
Postcode
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13.From what date are you married, in a civil partnership or cohabiting?
D   D
M M
 Y  Y  Y
15.Are you getting or have you applied for any social welfare payment(s)?
Name of payment:
Amount:
a week
,
.
Name of payment:
Amount:
a week
,
.
12.Are you?
Single
Married
Separated
Divorced
Widowed
Cohabiting
In a Civil Partnership
A surviving Civil Partner
A former Civil Partner
(you were in a Civil Partnership
that has since been dissolved) 
16.If you are getting a pension or allowance from another country, please state:
Name of country:
Your claim or reference
number:
Amount:
a week
,
.
14.Were you married in the Republic of Ireland?
Yes
No
If ‘No’, please submit a verified copy of your marriage certificate(See Part 9 Checklist for
details).
Yes
No
If ‘Yes’, please state:
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You are ‘employed’ when you work for another person or company and you get paid for this work. If
you are employed, please continue to complete the questions below. If you are currently self-employed
only, please go straight to question 24. If you are not employed, please go straight to question 23.
‘Gross pay’ is your pay before tax, PRSI, union dues or other deductions.
19.If you are currently employed, please state:
Employer’s name:
Employer’s address:
Gross weekly earnings:
a week (approximately)
,
.
Employer’s telephone
number:
Job title:
18.Are you currently
employed?
If ‘Yes’, please state:
Are you?
Employed only
Self-Employed only
Both
Yes
No
If ‘Yes’, please state:
D   D
M M
 Y  Y  Y
Dates you worked
there:
Type of work:
From:
To:
Note: A separate sheet of paper can be used for more details if needed.
17.Have you lived, been employed, or received a social welfare payment in another EU country
in the last 4 years? 
Country:
Employer’s name:  
Your social insurance
number while there:
Employer’s address:
M O B I L E
L A N D L I N E
Yes
No
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21.If you started work for the first time within the last 3 years, when did you start?
22.Are you related to your
employer?
If you are an employee your employer(s) must complete Part 4.
How are you related to
them?
D   D
M M
 Y  Y  Y
Yes
No
Your last employer’s
telephone number:
Job title:
23.If you are no longer in
employment, please state
the date you last worked:
D   D
M M
 Y  Y  Y
Your last employer’s name:
Their address:
Please enclose a copy of your P45 showing the date you last worked.
M O B I L E
L A N D L I N E
20.Do you currently have more than one employment?
Yes
No
Please note that if you have more than one employer, each employer must complete Part 4(a
photocopy of Part 4or a letter signed by your employer containing the same information will do).
Were you related to this
employer?
If ‘Yes’, how were you
related to them?
Yes
No
If ‘Yes’, please state:
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25.Please state your: 
Yourbusiness registration
number:
Business name:  
Business address:
Your business telephone
number:
26.When do you intend to
start maternity leave?
D   D
M M
 Y  Y  Y
M O B I L E
L A N D L I N E
27.Date you intend to return
to self-employment after
your maternity leave?
D   D
M M
 Y  Y  Y
28.Is your company a limited
company?
If‘Yes’, please attach a copy of your P35 for the relevant tax year (this is two years’ prior to 
the year in which your maternity leave starts).
Yes
No
29.Are you a sole trader?
If‘Yes’, please attach your self-assessment acknowledgement form you will have received
from the Revenue Commissioners and accompanying Form 11 for the relevant tax year (this
is two years’ prior to the year in which your maternity leave starts).
Yes
No
Remember to send in the relevant certificates and documents with this application.
24.Are you or have you ever
been self-employed?
Your occupation:
Date you started self-
employment:
If you recently started self-employment, please send confirmation of registration from Revenue.
If you are no longer self-
employed, when were you
last self-employed?
Yes
No
If ‘No’, please go to Part 3.
If ‘Yes’, please complete fully the remainder of this section.
D   D
M M
 Y  Y  Y
D   D
M M
 Y  Y  Y
If you are a sole trader, we accept your PPS number as your business registration number.
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If you want to get your payment direct to your current, deposit or savings account
in a financial institution, please fill in your account details below. Alternatively, if
you want us to make your payment to your employer, please fill in your employer’s
account details and sign the declaration below (payments can only be made to
accounts held in the Republic of Ireland).
I authorise the Department of Social Protection to pay my Maternity Benefit to my employer’s
account in a financial institution.
Signature(notblock letters)
Payment;direct;to;my;employer
Financial;Institution
Name of financial institution:
Bank Identifier Code (BIC):
International Bank Account
Number (IBAN):
Name(s) of account holder(s):
Name 1:
Name 2 (if any):
You will find the following details printed on statements from your
financial institution.  
Please state clearly who you wish your payment to issue to.
This payment should issue to:
You 
OR
Your employer
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30.What is your employee’s
full name? 
31.Please confirm their PPS
No.:                              
32.Please confirm the date
employee first started
working for you:
D   D
M M
 Y  Y  Y
D   D
M M
 Y  Y  Y
D   D
M M
 Y  Y  Y
34.Please give details of your employee’s PRSI record for the 12 month period immediately
before her maternity leave starts (e.g. If your employee’s maternity leave is due to start on
06/07/2015, you should provide her PRSI details for the period 06/07/2014 to 05/07/2015).The
forecasting of contributions is acceptable for any period after the 24th week of pregnancy.
35.If your employee has more than one class of PRSI (for example, if their PRSI changed from
Class A to Class J), please give details.
Period of
employment:
From:
To:
Number of weeks:
PRSI class:
Period of
employment:
From:
To:
Number of weeks:
PRSI class:
33.Please give full details of your employee’s maternity leave dates.  
D   D
M M
 Y  Y  Y
From:
To:
Employer’s section continued overleaf
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
!33".;
Note for Employer:
To qualify for the maximum 26 weeks Maternity Benefit, an employee must take
at least 2 weeks and at most 16 weeks leave before the end of the week in which
her baby is due. If your employee wishes to take the minimum 2 week period of
maternity leave prior to the birth of her baby, she should commence her
maternity leave on the Monday prior to the week in which her baby is due.
For example, if the due date is Wednesday 14/10/2015, the latest date the
employee should commence maternity leave is Monday 05/10/2015. 
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Warning: If you make a false statement or withhold information, you may be
prosecuted leading to a fine, a prison term or both.
Employer’s telephone
number:
Employer’s email address:
If you make any alterations after you complete the form, you must initial and
date them otherwise the information supplied cannot be accepted.
M O B I L E
L A N D L I N E
Employer8s;Contact;Details
PRSI class:
D   D
M M
 Y  Y  Y
  D
M M
 Y   Y   Y
I/We certify that the employee is entitled to the period of maternity leave stated above.
Signature(notblock letters)
Employer’s official stamp
Position in company or organisation
Date:
2
0
Your name (INBLOCK LETTERS)
36.Please confirm the date your employee was last present in the workplace and the class of
PRSI paid on that date:
Employer’s registered
number:
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