S.I. No. 286/1953 - Workmen's Compensation (Amendment) Act, 1953 (Prescri Bed Declarations) Regulations, 1953.

1. Surname of workman............................................................ ............................................................ ................

2. Full Christian names of workman ............................................................ .......................................................

3. Full address of workman ............................................................ ............................................................ ..........

4. Name and address of employer on whose behalf the Declaration is required.............................................

5. Is your wife, in respect of whom a supplemental allowance is being paid still alive ? (If not, give the date and place of death) ............................................................ ............................................................ ...................

6. Is the child or each of the children, in respect of whom a supplemental allowance is being paid, still alive ? (Give the name and date and place of death of any child who has died) ...................................................

7. Is the child or each of the children under the age of 15 years ? (Give the name and date and place of birth of any child who has reached the age of 15 years) ............................................................ ..........................

8. Are you receiving or claiming weekly compensation under the Workmen's Compensation Acts for another injury (accident or disease) from any other employer (or employer's insurer) ? If so, state the name and address of the other employer, and the amounts of the weekly compensation and supplemental allowances which you receive from such employer (or insurer) :—

............................................................ ............................................................ ............................................................ ..

............................................................ ............................................................ ............................................................ .

I DECLARE that all the information given above is true and correct.

Signature of Workman*....................

Date .......................

*Where the workman is unable, owing to illness or other reasonable cause, himself to sign the declaration, the wife or other representative of the workman should inform the employer (or his insurer) of the reason why he is unable to sign it and should complete the form so far as practicable.

GIVEN under my Official Seal, this 31st day of August, 1953.

SÉAMAS Ó RIAIN,

Minister for Social Welfare.

S.I. No. 286 of 1953.

WORKMEN'S COMPENSATION (AMENDMENT) ACT, 1953 (PRESCRI BED DECLARATIONS) REGULATIONS, 1953.

I, SÉAMAS Ó RIAIN, Minister for Social Welfare, in exercise of the power conferred on me by subsection (3) of

section 10

of the

Workmen's Compensation (Amendment) Act, 1953

(No. 25 of 1953), hereby make the following Regulations