DEPARTMENT OF SOCIAL PROTECTION - CHILD BENEFIT SECTION APPLICATION FORM CB1 - SUMMARY & FILLING STRUCTURE PART 1: YOUR DETAILS (PRIMARY CARER / MOTHER) - PPS Number: [XXXXXXX X] - Title: [Ms. / Mrs. / Mr.] - Surname: [SURNAME] - First Name: [FIRST NAME] - Maiden Name (if applicable): [MAIDEN NAME] - Date of Birth: [DD/MM/YYYY] - Current Address: [Address, City, Eircode] - Mobile Phone: [+353 XX XXX XXXX] - Nationality: Georgian (Stamp 1 / 1G / 4) PART 2: DETAILS OF CHILDREN FOR WHOM YOU ARE CLAIMING Child 1: - First Name: [Child First Name] | Surname: [Child Surname] - PPS Number: [Child PPSN] - Date of Birth: [DD/MM/YYYY] | Country of Birth: [Ireland / Georgia] - Relationship to you: [Son / Daughter] PART 3: HABITUAL RESIDENCE CONDITION (HRC) - Date you first took up residence in Ireland: [DD/MM/YYYY] - Are you currently employed in Ireland? [Yes / No] - Employer Name & Address: [Employer Company Ltd.] PART 4: PAYMENT DETAILS - Financial Institution: [AIB / Bank of Ireland / PTSB / Revolut] - Account Holder Name: [Your Full Name] - Account IBAN: [IE00 XXXX XXXX XXXX XXXX XX] - BIC / SWIFT: [XXXXXXXX] DECLARATION: I declare that the information given on this form is correct and complete. Signature of Claimant: ___________________________ Date: [DD/MM/YYYY] POST TO: Child Benefit Section, Department of Social Protection, St Oliver Plunkett Road, Letterkenny, Co. Donegal, F92 T449.