A P P L I C A T I O N TO OFFALY LOCAL AUTHORITIES FOR SOCIAL H O U S I N G S U P P O R THousing ApplicationCertificate of Income FormNAME:ADDRESS:REFERENCE NUM:PLEASE INSERT PHONE NO:FORM 1 – Please List Spouse/ Partner & All Occupants of Household who are part of our applicationSurname First Name Date ofBirthPPSNumberRelationshipto ApplicantGrossWeeklyIncome perWeekEmployerName &AddressI declare the above information to be correct:Signed:(Applicant)Date:Note: Certificate of Income should be submitted for all occupants of the household, whether fromEmployment/ Social Welfare or other. In the case of self-employed the most recent Notice ofAssessment should be submittedFAILURE TO DECLARE ALL HOUSEHOLD INCOME WILL RESULT IN YOUR REMOVAL FROMOFFALY COUNTY COUNCIL’S HOUSING LIST
Housing AuthorityReference No.:Please use BLOCK LETTERS.FORM 2 – Section AEMPLOYMENT DETAILS (Employed Person including Community Employment/ Back to Work Scheme)Name & Address:Is employed by me asPPS Number:Weekly Deductions from wages for:R.S.I. is € Only employee‟s share of P.R.S.I. should be shownIncome TAX € If No Income TAX is payable, insert “Nil” U.S.C. €Gross Weekly Wage € From (Date):Please note that Gross weekly wage should be inclusive of shift allowances and bonus payments but shouldnot include overtime.GROSS ANNUAL INCOME: € FOR YEAR ENDING 31 ST DECEMBER 2010Is EmploymentPermanent Temporary Part-Time Community Employment Back to Work SchemeCommencement Date:Certified Correct: (Employers Signature)Date:Employers Name:Address:Registration Number:Phone Number:Employers Official Stamp and Registration No.FORM 2 - Section BIf applicants are in receipt of any other Income (i.e. Family Income Supplement) please confirm Amount andSource.Name: € per week Source:Name: € per week Source:Are you in receipt of Family Income Supplement? Yes NoIf Yes please state amount per week €To be certified by Employer, Social Welfare Officer or Community Welfare Officer.Signed: Position: Date:
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