• You should only use this form if you are getting one of the payments overleaf

Signature (not block letters)

3. Surname:

* If you opt to receive your Fuel Allowance in two payments, these will issue at two intervals during

the Fuel Allowance season. If the Fuel Allowance season has already started you will continue to

receive weekly payments until the next payment period is due and then your weekly payment will

changeover. The two payments are generally made at the start and midway through the Fuel Season.

Date:

YYYYMMDD

6. Your address:

M O B I L E

L A N D L I N E

7. Your telephone number:

Part 11. Your PPS No.:

Your own details

2. First name(s):

Contact Details

4. Your date of birth:

2 0

5. What payment do you get from this Department?

County Postcode

I wish to change the payment frequency of my Fuel Allowance to: (Insert an 'X' in one of the

boxes below).

Application form to Data Classification R

Social Welfare Services

FA CPF 1

Part 2 Your payment preference

ORTwo payments for the Fuel Season* Weekly during the Fuel Season

YYYYMMDD

• Please use BLACK ball point pen.• Please use BLOCK LETTERS and place an X in the relevant boxes.

• To apply for Fuel Allowance please complete and return application form NFS 1.

Change the Payment Frequency of Fuel Allowance

and also getting a Fuel Allowance and wish to change your payment frequency.

8032199473

Send this completed application form to:

You must be getting one of the payments listed below to change the payment

frequency of your Fuel Allowance.

If you are getting any of the following payments:

• Jobseeker's Allowance

Note:

Data Protection Statement

The Department of Employment Affairs and Social Protection will treat all information

and personal data you give us as confidential. However, it should be noted that information may be

exchanged with other Government Departments / Agencies in accordance with the law.

• Disability Allowance

• Invalidity Pension

• Incapacity Supplement under the Disablement Pension

Scheme

• Death Benefit Pension under Occupational Injuries Benefit

Scheme

Non-Contributory)

• Blind Pension

• Deserted Wife's Benefit or Allowance

• State Pension (Contributory or Non-Contributory)

• Guardian's Payment (Contributory or Non-Contributory)

• Widow's, Widower's or Surviving Civil Partner’s Pension

(Contributory or Non Contributory)

• Social Security Payment from a country covered by EU

Regulations or a country with which Ireland has a Bilateral

Social Security Agreement (of which there is an Irish

equivalent payment).

• Farm Assist

• One Parent Family Payment

• Jobseeker’s Allowance Transition

• Back to Work Enterprise Allowance

Send this form to:

Send this form to the office

dealing with your payment.

College Road

Sligo

Social Welfare Services

(071) 915 7100Telephone:

LoCall: 1890 500 000

Ballinalee Road

Longford

Telephone:

LoCall: 1890 927 770

(043) 334 0000

Social Welfare Services

9112597004

The rates charged for the use of 1890 (LoCall) numbers may vary among different service providers.

Explanations and terms used in this form are intended as a guide only and are not a legal interpretation. 20K 02-18 Edition: December 2017