Worksheet labelled "PART B Application Form" (To be completed in full by Department of Social Protection (DSP)

APPLICATION FOR PARTICIPATION ON THE RURAL SOCIAL SCHEME(RSS) 2017/2018 Worksheet labelled "PART A - Application Form" (To be completed in full by Applicant) Worksheet labelled "PART B Application Form" (To be completed in full by Department of Social Protection (DSP) Partner* - Where partner is referred to in this document it should be read as Spouse/Civil Partner/Cohabitant PART A APPLICANT INFORMATION Section 1 Personal Details Only the person who intends to participate on the RSS should complete this form. 1.1 Name: 1.2 Address: 1.3 Birth Surname (if different): Please note the following format must be used when inputting dates throughout the document: 1.4 Date of birth: (You must submit your Birth Certificate/Driving Licence to your local Implementing Body for verification): 1.5 Length of time at the above address: 1.6 Contact Telephone No: 1.7 Civil Status: Please select as appropriate: Married, Single, Widowed, Cohabitating*, In a Civil Partnership, Separated or Divorced *means you live with a man or woman as husband and wife and you are not married to them 1.8 Nationality Figures Letters 1.9. PPS Number: Should consist of 7 digits and 1 letter (in some cases there may be 2 letters, the last letter should be W ) Page 1 of 7

Section 2 2.1 Are you receiving any Department of Social Protection (DSP) payment excluding Child Benefit at the moment? RSS Eligibility Details If Yes please state: The name of payment: Date of Award (): Current weekly payment: (exclude free fuel allowance if applicable) 2.1 a Are you awaiting on a decision on any DSP payment you have claimed for? If Yes please state: The name of payment: Date on which the payment was applied for: 2.1b Are you currently on Jobpath or any other activitation scheme? If Yes please state: Name ofof the scheme Date commenced 2.2 Are you currently on unpaid leave from employment? Applicants on Jobpath or other activation schemes are not eligible for RSS If Yes please specify the nature of the leave: If 'other' please specify: (Carer's, Maternity, Adoptive, Illness or Other) Date you commenced this leave (): 2.3 Please complete (A) if you are a farmer and (B) if you are a fisherman: (A) FARMERS (i) To be eligible to join the Rural Social Scheme, you must provide proof to your Implementing Body that you are actively farming by providing a copy of one of the following: (a) Your application for the EU Basic payment Scheme for the current year, which includes a valid herd number together with a copy of the associated receipt (official proof of postage) or (b) For online EU Basic Payment Scheme Applications please include a copy of the "Review and Submit" page and a copy of the "Confirmation" page for the current Scheme year If you wish to join the RSS but do not have the requested documentation and are actively farming i.e. have animals or growing crops for feed, you can submit an EU Basic Payment Form to the Department of Agriculture, Fisheries and Food, Basic Payment Unit, Old Abbeyleix Road, Portlaoise, Co. Laois, and forward a copy of your application along with a copy of the associated receipt to your local Implementing Body. Your Implementing Body will be able to advise you further in this regard. Have you supplied the documentation requested at (a) or (b) above? If Yes please state type of documentation supplied If No, please provide reason: (ii) Please insert your Herd / Flock (Sheep) /Equine/Pig Number (as per EU Basic Payment Scheme) (iii) Is the above number in your name? If 'Yes', please complete Questions (iv) to (x) If 'No' please complete Questions (v) to (x) Page 2 of 7

(iv) Please state the name of the person in whose name the Herd/Flock/Equine/Pig Number is held: Is the above number in your Partner s* name: Father/Mother s name: Brother/Sister s name: any other relationship: If Yes to any other relationship, please provide details: If you have selected 'Yes to a Transfer on the previous page, a Use of Basic Payment Scheme Application Form needs to be completed for the period up to the 31 st March 2018. Please ask your local Implementing Body for the Form. To be completed by the applicant only: (v) Are you actively farming? (vi) If Yes please state if you own, rent or lease the land: (vii) Number of hectares farmed: (As per your EU Basic Payment Form) Your local Implementing Body will be able to advise you further. (viii) Do you intend to actively farm this land from the date of your application to join the RSS to 31 st March 2018? If No, please provide details (ix) If the farm is not adjacent to your home, how many miles is the farm from your home address? (x) Have you rented or leased any part/all of your land to someone else? (To participate on this Scheme you must farm a minimum of 1 Hectare of land within the State) (To be eligible, you must be permanently residing within 70 miles by road of the holding i.e. within daily commuting distance) If Yes, please provide details: (B) FISHERMEN In the case of a fisherman in order for you to be deemed eligible for a place on the Rural Social Scheme, you must provide proof to your Implementing Body that you are actively engaged in fishing by providing a copy of a relevant licence or permit (the relevant licence/permit must meet one of the eligibility categories set out by the Department of Social Protection, details of which are available from your local Implementing Body). Please insert the relevant Licence/Registration number in the appropriate box: Fish Licence No. Boat Reg.No. Other No. Please specify: Date Issued: () Period Covered: Is the above number in your name? Is the above number in your Partner s* name? If you are joining the RSS on the basis of holding a Commercial Salmon Fishing Licence please complete the questions below: Are you actively fishing? Do you hold a current licence? If No do you intend to re-apply for a licence? Page 3 of 7

Section 3: Are you joining the RSS as a result of a Spouse/Civil Partner/Cohabitant Transfer (Social Welfare Payment)? 3.1 If you have answered 'Yes', please complete this section, otherwise go straight to Section 4. If Yes please state: Type of payment: Date of award: Rate of payment: () Please note: To be eligible to participate on the Rural Social Scheme, your Partner* must continue to satisfy the underlying conditions of the original qualifying payment. If your Partner* is due to reach 66 years before the end March 2018, please note that your participation on the RSS will cease with effect from the day before your Partner* reaches 66 years. Your Partner* should apply for a pension in their own right at least 6 months prior to their 66th Birthday in order to avoid undue financial pressure. If your Partner* is then awarded a Non-Contributory State Pension and an increase in respect of a Qualified Adult, you may then submit a new application for participation on the scheme under the eligibility category of Adult Dependant of a recipient of the Non-Contributory State Pension. Section 4 4.1 Are you in insurable employment other than the RSS? If Yes, please provide the following details: Gross earnings (input into appropriate box) Weekly Fortnightly Monthly Date of commencement of employment: Personal Employment Details Outside the RSS () Were the above earnings assessed by the DSP when calculating you or your Partner's* Social Welfare Payment? If Yes please state, Date of assessment? () Note: As a Participant on the RSS, you are permitted to undertake work outside of either farming/fishing. However, any such work must not interfere with work on the RSS or the times that you are expected to work. If you are eligible to participate on the RSS, your employment on the RSS will be your main employment and the onus is on you to contact the Revenue Commissioners with regard to any other work undertaken to ensure tax compliance etc. Your earnings should also remain within the income threshold which applies to your underlying Social Welfare Payment. Section 5: Do you have a Partner*? If 'Yes', please complete questions 5.1 to 5.7, otherwise go to Section 6. 5.1 (a) What is your Partner s* name? (b) What is your Partner s* PPS Number? (c) What is your Partner s* Date of birth? Figures () Letter(s) You must submit a Birth Certificate to your local Implementing Body for verification of DOB 5.2 Is your Partner* in receipt of a DSP payment, excluding Child Benefit? If 'Yes', please complete Form RSS5 (available from your local Implementing Body) If 'No', Has your Partner* applied for a payment from DSP? If 'Yes', please state type of payment: Please Note: You should notify your Implementing Body immediately if you or your Spouse/Civil Partner/Cohabitant apply for a payment from DSP and also on receipt of any decision, as this may affect your payment on the RSS. Page 4 of 7

5.3 Is your Partner*: a) In Insurable Employment? b) Self-Employed? Or participating on: c) A Community Employment (CE) Scheme? d) Any other employment/training course? If yes to c or d above please: State the title of the Scheme/Course: Date your Partner* commenced the Scheme/Course: Date your Partner* will complete the Scheme/Course: NB: Complete the following declaration, where applicable, otherwise write N/A: If your Partner* is not in insurable employment, please complete the following declaration: I (applicant name - block caps) Please answer 'Yes' or 'No' to all questions wish to confirm that my Partner* (name - block caps) is not in insurable employment or participating on a Community Employment (CE) Scheme or any other course at this time. I understand that should this change, I must notify my supervisor immediately. Signed: (by applicant) Date: 5.4 Has your Partner* any other income which is not listed in question 5.3 above? If Yes please provide details and submit the relevant documents e.g. a social security pension from another country, private or state pension etc. to your Implementing Body. Section 6: Will you or your Partner* reach 66 years of age before 31st March 2018? If 'Yes' please complete Section 6.1 and 6.2, otherwise go to Section 7. Please note: You or your Partner* should apply for a pension at least 6 months prior to your 66th Birthday in order to avoid undue financial pressure. 6.1 (a) Will you reach 66 years before 31 st March 2018? (b) Will your Partner* reach 66 years before 31st March 2018? If Yes, please state Partner s* Date of birth: If you are eligible to participate on the RSS and reach 66 years before 31 st March 2018, your participation on the RSS will cease with effect from the day before you reach 66 years. If your Partner* reaches 66 years before the 31st March 2018, any increase for Qualified Adult Allowance payment within your RSS payment will cease with effect from that date. Page 5 of 7

Section 7 7.1 Child Dependant Details (If applicable): If space is not sufficient, please provide remainder of information on a separate sheet. Child Dependant Details A Rural Social Scheme form entitled Certificate of Participation in full-time Education EP2, must be requested from your local Implementing Body, completed and then returned to your local Implementing Body in respect of any Child Dependant(s) over 18 years of age and in full-time education. Full Name Date of Birth Details of School/College/University Date child will cease college Is child dependant in receipt of a DSP payment in their own right excluding Child Benefit? Relationship to child You must submit a Birth Certificate to your local Implementing Body in respect of each child in order to confirm each child's Date of Birth. If you are in receipt of a foster care allowance in respect of any of the children named above you may be entitled to a CDI(Child Dependant Increase) payment. Section 8 8.1 Bank Account Details: Name of Bank: Account Name/s: Address of Bank: Bank Account Details Account Number: Sort Code: Section 9 Types Of Work Undertaken 9.1 Please give details of preferred geographic work area(s), if any: 9.2 In order of preference (1-7), please indicate below the type(s) of work you would prefer to undertake: Section 10 1. Maintaining and enhancing way-marked ways, agreed walks and bog roads 2. Energy conservation work for the elderly and the less well off 3. Village and countryside enhancement projects 4. Social care and care for the elderly, community care for both pre-school and after-school groups 5. Environmental maintenance work maintenance and care-taking of community and sporting facilities 6. Projects relating to not for profit cultural and heritage centres 7. Community administration /Clerical duties 10.1 Other comments/relevant information you wish to include on your application: Further Information Page 6 of 7

Section 11 Declaration Of The RSS Applicant I wish to apply for a place on the Rural Social Scheme. I declare that the information I have provided above is correct. Should there be any alterations whatsoever in my circumstances, which may affect my participation or payment under the Rural Social Scheme, I will inform (insert Implementing Body s name here) with immediate effect. I understand that by completing this form, there is no obligation on the Implementing Body to guarantee me a place on the RSS. I also understand that if my application on the RSS is successful, I will be permitted to undertake work outside of either farming or fishing. However, any such work must not interfere with my work on the RSS or the times that I am expected to work. I am also aware that my employment on the RSS is my main employment and undertake to contact the Revenue Commissioners with regard to any other work undertaken to ensure tax compliance etc. and that my earnings should also remain within the income threshold, which applies to my qualifying Social Welfare Payment. Furthermore, I agree and understand that: Any failure on my part to declare any change(s) in my circumstances may affect my continued participation on the RSS; Failure to declare any change(s) in my circumstances to my Implementing Body in a timely manner may result in an overpayment of my RSS weekly payment. Under such circumstances, I will be required to repay the value of that overpayment, with a schedule agreed with my Implementing Body, and in line with the Department's Overpayments Policy; The Department of Social Protection reserves the right to have my eligibility as a Participant re-assessed at any time; If either myself or my Partner* are awarded a Social Welfare payment while I am participating on the RSS I will inform the Implementing Body immediately; Garda clearance may be obtained on my behalf; On taking a place on the RSS under one of the following eligible Social Welfare Payments: Farm Assist, Fish Assist, Job Seeker s Allowance, I will notify the DSP with immediate effect to ensure that I do not receive the above payments while I am working on the RSS. On taking a place on the RSS under one of the following eligible Social Welfare headings: Disability Allowance - I will continue to receive my payment from the DSP and receive a top-up payment on the RSS. One Parent Family Payment I will continue to receive my payment from the DSP and receive the RSS personal rate only for my participation on the RSS. My One Parent Family Payment may be adjusted to take into account my income from RSS On taking a place on the RSS under one of the following eligible Social Welfare headings: Widow(ers) Pension, (Contributory or Non-Contributory) or as an Adult Dependant of a Non-Contributory State Pensioner I will continue to receive my payment from the DSP and receive a top-up payment for my participation on the RSS. Although I will be receiving two payments, it will be equivalent to the amount I would receive if one payment was made under the RSS. If during the contract year, I become eligible to claim one of the above payments, I must apply to the DSP for the payment and inform my local Implementing Body immediately. If I am awarded any of the above payments, I will receive my payment from the DSP and my payment on the RSS will reduce to a top-up payment to bring me in line with my existing rate of payment on RSS. Applicant s Signature: Date: Print Name : For completion by the Manager: Manager s Signature: Print Name: Date of receipt of this application: If a previous application form has been submitted by this applicant please state the original date of receipt of application on file: Note for Supervisors: Please ensure this application form is fully completed, stamped with the company stamp and that the checklist is completed and that you are satisfied that Part A matches Part B before forwarding the application to Pobal. Date: Date: Date: Company Stamp Page 7 of 7

PART B TO BE COMPLETED BY A DEPARTMENT OF SOCIAL PROTECTION OFFICIAL ONLY (Participant/Implementing Body must not complete this form.) ***Form to be completed within 14 days prior to applicant starting on RSS*** 1. Customer's Name: 2. Customer's PPS Number: 3. Spouse/Civil Partner/Cohabitant's Name: 4. Spouse/Civil Partner/Cohabitant's PPS Number: Figures 5. Please confirm whether the person applying for the RSS is the Spouse/Civil Partner/Cohabitant or the Customer (please input as appropriate): Letters Note to DSP Official: Placement on the Rural Social Scheme can be transferred between Spouse/Civil Partner/Cohabitant. Where this is the case, please advise customer about signing for credits where there is an entitlement to credits. 6. Please provide a full detailed breakdown of the Customer s Current Weekly Social Welfare Payment: 6 a.type of Payment: 6 b.currently on Jobpath yes or No 6c. Date commenced Jobpath Note to DSP Official: If Customer is on JOBPATH then DO NOT COMPLETE THIS FORM as applicant is ineligible to commence on RSS Note to DSP Official: Please provide full details of payment scheme, including Contributory/Non-Contributory/Assistance or Benefit, where applicable. Please also provide a full breakdown of the customer s payment to include, where applicable, the monetary value of means and the monetary value of the IQA. Date of award: Personal Rate: Increase for Qualified Adult: TOTAL WEEKLY PAYMENT: (IQA) Child Dependant Increase(s): (CDI) Means: No. of Dependent Children: Free Fuel: Child Dependants Full Name Date of Birth

7. (i) Has the applicant been approved for a Fuel/Smog Payment? Please answer this question even if Free Fuel is not in payment at present (iii) If Yes, please state the weekly amount payable in last Fuel Season: (iv) If No, did the applicant ever apply for a Fuel Allowance? (v) If Yes to (iv), can you please provide the reason why the claim was refused/withdrawn: 8. Claim Paid Days: If customer has means assessed, please state source(s) of means: 9. Date of last means review (please refer to most recent review carried out): Please ensure any dates requested are inserted or mark N/A. 10. Is the Spouse/Civil Partner/Cohabitant claiming a Social Welfare Payment? If Yes, please state: Type of payment: Date of award: Personal Rate: IQA: CDI: No. of Dependant Children: Means: Free Fuel: Rate of payment: 11. Is the Spouse/Civil Partner/Cohabitant participating on a publicly funded Scheme e.g. FÁS or any other course? If Yes, please provide the following if available: Type of scheme/course: Date of commencement: Rate of payment: Date scheme/course will cease: Signed: Date: Print Name: Name of Local Office: DSP Local Officer Local Office Stamp

CHECKLIST AND HELPSHEET FOR IMPLEMENTING BODY IN RESPECT OF APPLICATION FOR THE PARTICIPATION ON THE RURAL SOCIAL SCHEME 2017/18 PART A APPLICANT INFORMATION Section 1 Personal Details 1.1 Please ensure this corresponds with Question 1 in Part B (Part B to be completed by the local DSP Office) 1.8 Please ensure this corresponds with Question 2 in Part B Figures Letters PPS Number: Should consist of 7 digits and 1 letter (in some cases there may be 2 letters, the last letter should be W ) Section 2 2.1 Please ensure this corresponds with Question 6 in Part B If Yes please state: (A) FARMERS (ii) Please insert your Herd / Flock (Sheep) /Equine/Pig Number This number should have 1 letter and 7 digits as per EU Basic Payment Scheme RSS Eligibility Details 3.1) Section 3 must be completed in all Spouse/Civil Partner/Cohabitant swap cases mark N/A if not applicable. Section 5 5.1) Please ensure (a) and (b) correspond with Questions 3 and 4 in Part B. 5.2) Please ensure this corresponds with Question 13 in Part B. 5.3) Please indicate Y or N to all (a,b,c, and d) Questions. 5.5) Where applicable, please ensure the declaration is completed. Section 6 Spouse/Civil Partner/Cohabitant Details Personal and Spouse/Civil Partner/Cohabitant Pension Entitlements If Section 6 is not applicable, please strikethrough and write N/A. Section 7 8.1) Bank Account Details: The name of payment: Section 3 Please complete if you wish to join the scheme as a result of a Spouse/Civil Partner/Cohabitant Transfer (Social Welfare Payment) Spouse/Civil Partner/Cohabitant s PPS Number - Should consist of 7 digits and 1 letter (in some cases there may be 2 letters, the last letter should be W ) Section 8 Account Number: This will always be 8 digits Sort Code: This will always be 6 digits In order to validate the bank account details, please log onto www.ipso.ie Child Dependant Details Please cross-reference Child Dependant Details in Section 7 Part A, with Child Dependant Details provided by SW in Question 6 Part B and request copies of Birth Certificates for each child to verify DOB Bank Details