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Certification of Request for Benefits or MediCare

Certification of Request for Benefits or MediCare

Name:
Last Name:
Mailing Address (not in U.S.):
Phone Numbers (add Country Code if not in the Republic of
Ireland): 		1) Daytime Phone
2) Evening Phone
3) Mobile / cell
Your email address:
Social Security Number: (Last 4 digits)
Date of birth:
Are you unable to work because of a disability?:
Are you working more than 45 hours per month?:
Personal Public Service Number (PPS No. or PPSN):
Additional Information:
   
If You Are Married please also complete  
Name of spouse:
Last Name of spouse:
Spouse’s Date of Birth:
Social Security Number (SSN) of Spouse if they have one: (Last 4 digits)

The information you provide is used solely by the Federal Benefits Unit of the U.S. Embassy in Dublin. In order to process certain types of requests, we may have to ask for your Social Security Number (SSN) or the last 4-digits thereof, your date of birth, or your banking information. You may decline to provide such information, but that could inhibit our ability to answer your questions or assist you with your request. Any information provided on our web form is not retained and is used only in order to process your current request or answer your current questions. The Dublin FBU Office works in accordance with SSA procedures as well as the Paperwork Reduction Act (44 U.S.C. 3501 et seq.) and the Privacy Act of 1974. You can read our full privacy statement at http://www.socialsecurity.gov/info/isba/privacyact.htm