S.I. No. 3/1953 - Unemployment Assistance (Qualification Certificate Regulations) (Amendment) Order, 1953.

1. Name of applicant....................................Number of Insurance Card..................

2. If you are a married woman

(a) Husband's Christian Names............................................................ .............

(b) Number of his Insurance Card............................................................ .........

(c) Are you living with your husband ?...........................................................

(d) If you are not living with your husband—

(i) Does he contribute to your maintenance and if so, how much?............................................................ ...............................................

(ii) Where does he reside ?............................................................ ....................

(e) If you are claiming your husband as a dependant—

(i) Is he incapable of supporting himself? If so, state reason............................................................ ................................................

(ii) Do you wholly or mainly maintain your husband ?..................................

(f) If your husband is claiming or in receipt of Disability or Unemployment Benefit or any pension, allowance or assistance, give particulars............................................................ ......

3. If you are claiming as dependants a child or two children under 16 years of age :—

(a) Particulars of children :—

Name of Child

Date of Birth

Relation to you

Does childship reside with you?

Surname

Christian Names

Day

Month

Year

(1)

(2)

(3)

(4)

(5)

(6)

(b) Are you in receipt of Children's Allowances? If so, state Claim Number shown on your Allowance Book

(c) State total number of children under 16 years of age in your household

(d) Is any allowance (other than a Children's Allowance), benefit, pension or assistance payable, either to you or to any other person, in respect of any child who is in your household or who normally belongs to your household? If so, give particulars

I have clearly understood the above questions and to the best of my knowledge and belief all the statements made by me in this application are correct.

I, hereby, apply for a Qualification Certificate under the Unemployment Assistance Acts, 1933 to 1952.

Signature (or mark) of Applicant............................................................ ............................................................ .

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

Signed (or mark made) in my presence

Witness............................................................ ............................................................ .............................................

Address ............................................................ ............................................................ .............................................

STATUTORY DECLARATION BY APPLICANT.

I, ............................................................ ............................................................ ...................... do solemnly and sincerely declare that to the best of my knowledge and belief all the statements which I have made in this application are true, and all the questions therein which I have answered are truly and fully answered in all respects, and I make this solemn declaration conscientiously believing the same to be true and by virtue of the

Statutory Declarations Act, 1938

(Signed)............................................................ ............................................................ ....................................................

Declared before me by............................................................ ....... at............................................................ .........

this ............................................................ ........ day of............................................................ ....................................

(Signed)............................................................ ...

Peace Commissioner or Duly Authorised Officer.

SECOND SCHEDULE.

UNEMPLOYMENT ASSISTANCE ACT, 1933

.

QUALIFICATION CERTIFICATE.

Number................................

It is hereby certified that............................................................ ............................................................ ................

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

............................................................ ................................................(............................................................ ..................) residing at............................................................ ............................................................ ...............................................

fulfils the conditions set out hereon.

The Holder's weekly rate of means corresponding to the annual rate calculated in accordance with the

Unemployment Assistance Act, 1933

, is............................................................ .......................................................

Official Stamp.

Deciding Officer............................................................ .......................

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

Signature of Holder............................................................ ..................

Witness to signature............................................................ ................

To be completed immediately on receipt of certificate.

Address............................................................ .......................................

The conditions to be fulfilled by a person obtaining or holding a qualification certificate under the

Unemployment Assistance Act, 1933

, are :—

(a) that he is at the date of the application, resident in the State and has at any time, been resident in the State for a continuous period of at least six months ;

(b) that he has attained the age of eighteen years and has not attained the age of seventy years ;

(c) that his means, calculated in accordance with this Act, do not exceed, in case he is resident in an urban area, ninety-eight pounds and sixteen shillings or, in case he is resident elsewhere in the State, seventy-two pounds and sixteen shillings per annum ;

(d) in the case of a married woman either—

(i) that her husband is a dependant of her, or

(ii) that neither she nor her husband is a dependant of the other and she has one or more dependants ;

(e) in the case of a widow or spinster, that she has one or more dependants ;

(f) in the case of a widow or spinster who has no dependant, that not less than fifty-two contributions have been paid in respect of her during the appropriate period.

GIVEN under the Official Seal of the Minister for Social Welfare, this 2nd day of January, 1953.

(Signed) SÉAMAS Ó RIAIN,

Minister for Social Welfare.

4. Married/Single/Widower/Widow............................................................ ...........................................................

5. Date of Birth............................................................ ............................................................ ....................................

6. Have you been resident in the State for a continuous period of at least six months ?.................................

7. Give Particulars of Employment During the Past Two Years :—

Employer

Occupation

Period

From

To

8. Have you a farm, a business, or any house or other property, or have you any right in any property?

(a) If so, state where it is situated............................................................ ..................................

(b) Describe it giving such particulars as Poor Law Valuation, Rent, turnover, etc............................................................ ............................................................ .....................

9.(a) Do you pay rent for the house or lodging in which you reside, or do you own it?............................................................ ............................................................ ................................

(b) If you pay rent, give particulars, stating whether it is payable under a lease or a yearly or shorter tenancy............................................................ ............................................................ ..............

10. *How much have you coming in per week in money ?............................................................ ....

(a) From what sources is such money derived ?............................................................ .....

(b) What contributions do you receive from members of your household or others towards household expenses ?............................................................ ..........................................

*The following should not be included :—

(a) Money earned in respect of current personal employment under a contract of service.

(b) Money received by way of disability benefit, unemployment benefit, marriage benefit or maternity benefit under the

Social Welfare Act, 1952

, or by way of unemployment assistance under the Unemployment Assistance Acts, 1933 to 1952, or allowances under the Social Welfare (Children's Allowances) Acts, 1944 to 1952.

(c) Money received by way of Home Assistance.

(d) Income from money or property described elsewhere in this form.

11. Have you money in hand, at Bank, or invested ?............................................................ ................

12. Have you money coming in from any other source ?............................................................ .........

13. What other means of subsistence have you ?............................................................ .....................

14. Have you had in the last twelve months any property or income which you do not own or receive at present? If so, what has become of it?............................................................ .................................

15. (a) If you do not own or pay rent for your house or lodging, with whom do you reside?............................................................ ............................................................ .........................

(b) What is your relationship to such person ?............................................................ .................

(c) What contribution do you make for your board and/or lodging?............................................................ ............................................................ ................

16. Have you previously applied for a Qualification Certificate? If so, state when and where............................................................ ............................................................ ......................................

I have clearly understood the above questions, and to the best of my knowledge and belief all the statements made by me in this application are correct.

I, hereby, apply for a Qualification Certificate under the Unemployment Assistance Acts, 1933 to 1952.

Signature or mark of Applicant............................................................ .......................................................

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

Signed (or mark made) in my presence

Witness............................................................ ............................................................ ....................................

Address............................................................ ............................................................ ....................................

STATUTORY DECLARATION BY APPLICANT.

I, ............................................................ ............................................................ ...................... do solemnly and sincerely declare that to the best of my knowledge and belief all the statements which I have made in this application are true, and all the questions therein which I have answered are truly and fully answered in all respects, and I make this solemn declaration conscientiously believing the same to be true and by virtue of the

Statutory Declarations Act, 1938

.

(Signed)............................................................ ............................................................ ...................................................

Declared before me by............................................................ ............at............................................................ ..........

this............................................................ .....day of.....................................................(Signed)..................................

Peace Commissioner or Duly Authorised Officer.

CONTINUATION OF APPLICATION FOR A

QUALIFICATION CERTIFICATE

(To be completed by women applicants with dependants)

S.I. No. 3 of 1953.

UNEMPLOYMENT ASSISTANCE (QUALIFICATION CERTIFICATE REGULATIONS) (AMENDMENT) ORDER, 1953.

The Minister for Social Welfare, in exercise of the powers conferred on him by subsection (1) of

section 7

of the

Unemployment Assistance Act, 1933

(No. 46 of 1933), as adapted by the Social Welfare (Transfer of Departmental Administration and Ministerial Functions) (No. 1) Order, 1947 (

S. R. & O. No. 18 of 1947

), hereby orders as follows