MAYO FIRE SERVICE

Application Form for Waiver of Fire Service Charges

Invoice Number:

1. Name:
2. Address:
3. Home Telephone
Mobile Telephone
4. Do you reside alone? / Yes □ No □
If “No” please give full details of all other residents in the household together with details of their income or schools which they are attending
Name / Relationship to Applicant / Age / Sources of Income / Name of School / Amount of Income per week

5. If you have a medical card please enter medical card number here

6. Are you the owner of
the Property?
If “No” state name and
address of landlord / Yes □ No □
Name:
Address:
7. Is this your principal
place of residence? / Yes □ No □
If no, please give details of
principal residence
8. Are you or any member of your household the owners of
any land, property or business other than that listed above? Yes □ No □
If yes, please give details of
annual income from same.

Details of Income:

9. If on pension or social welfare allowance please complete this section

Type of Pension. Please tick () / Contributory □ Non Contributory □
Pension Book Number
Amount of Pension
Weekly / Monthly
10. If on jobseeker’s benefit, disability benefit or other social welfare allowance this
section should be completed and stamped in your local Department of Social and
Family Affairs office:
I hereby certify that:
Name
Address
Is in receipt of
(Type of Payment)
From (date)
And is being paid at a rate of (amount per week)
Since (date)
RSI Number
Signed: / Date:
Title: / Official Stamp:
11. If employed please give
name and address of your
employer:
Employer’s Name:
Employer’s Address

Please submit P6O for the tax year ending on the 5th April last with this form. If self-employed or fulltime farmer, a copy of your tax returns for year ending 5th of April last should be submitted with this form.

  1. If any other source of income – specify source and weekly income of same:

______

13. Insurance Details (tick appropriate box):

Have you insurance cover for this type of /fire / Incident? Yes □ No □

If “Yes” please give Policy No. ______

Has a claim been submitted to your Insurers: Yes □ No □

If it has, is the fire fee/charge fee included in the claim: Yes □ No □

If you have please give the following information:

Name & Address of Insurers:

______

I hereby declare that the foregoing particulars are true, correct and complete to the best of my knowledge and I authorise MayoCounty Council to make any necessary enquiries to validate my application.

Signed:______Date: ______

Please note that failure to furnish information or giving misleading information will automatically disqualify the applicant from any waiver of charges.

Return completed form to:

Chief Fire Officer,
Fire Brigade H.Q.,
Humbert Way,
Castlebar,
Co. Mayo. / Tel: (094) 9021211
Fax: (094) 9024137
Email:
Web: