SW-1

APPLICATION
FOR DETERMINING THE RIGHT TO THE EDUCATIONAL BENEFIT

1. Familiarize yourself with the terms of entitlement to the childcare benefit included in the instruction in PART II of the application.
2. Complete with CAPITAL LETTERS.
3. The fields "Series and number of the identity document" apply only to those people who have not been given a PESEL number.
4. Select the check boxes v or X.

The application concerns the period for which the right to a child benefit is determined (1): 20 .... / 20 ....
(1) Beginning with the period commencing on June 1, 2021, the period for which the right to childcare benefit is determined runs from June 1 to May 31 of the following calendar
year.

NAME OF THE COMPETENT AUTHORITY HANDLING THE EDUCATIONAL BENEFIT PROCEDURE (1)

ADDRESS OF THE COMPETENT AUTHORITY HANDLING PROCEDURES ON THE EDUCATIONAL BENEFIT (1)
01. Commune / District

02. Postal code 03. City

-
04. Street

05. House number 06. Apartment number

(1) The competent authority is understood as the commune head, mayor or president of the city competent for the place of residence of the person submitting the application.

PART I.
1. Details of the person submitting the application for establishing the right to a child benefit, hereinafter referred to as the "applicant".

APPLICANT'S DETAILS
01. Name

02. Surname

03. PESEL number 04. Date of birth: (dd / mm / yyyy) 05. Series and number of the document confirming identity (1)

06. Citizenship

07. Marital status (2)

(1) Fill in only if a PESEL number has not been issued.

(2) Enter as appropriate: virgin, single, married, married, divorced, divorced, separated (only if adjudicated by a final court judgment),
widow, widower.

ADDRESS
01. Commune / District

02. Postal code 03. City

-
04. Street

05. House number 06. Apartment number 07. Telephone number (1)

08. Electronic mail address - e-mail (2)

(1) The number is not mandatory but it will facilitate contact regarding the application.
(2) At the e-mail address provided, you will receive information about granting the childcare benefit, it will facilitate contact regarding the application and its submission
is obligatory when you submit the application electronically.

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2. Establishing the right to a child care benefit for a child / children under the age of 18.
I am applying for a child benefit for the following child / children living with me and dependent on me (child benefit for a child is granted until the child turns
18 and is due regardless of
earned income):

CHILD DATA - 1
Name:

Name:

PESEL number: Date of birth: (dd / mm / yyyy) Series and number of the identity document: (1)

Citizenship:

Marital status: (2) Gender: (enter: F - female, M - male)

CHILD DATA - 2
Name:

Name:

PESEL number: Date of birth: (dd / mm / yyyy) Series and number of the identity document: (1)

Citizenship:

Marital status: (2) Gender: (enter: F - female, M - male)

CHILD DATA - 3
Name:

Name:

PESEL number: Date of birth: (dd / mm / yyyy) Series and number of the identity document: (1)

Citizenship:

Marital status: (2) Gender: (enter: F - female, M - male)

CHILD DATA - 4
Name:

Name:

PESEL number: Date of birth: (dd / mm / yyyy) Series and number of the identity document: (1)

Citizenship:

Marital status: (2) Gender: (enter: F - female, M - male)

(1) Fill in only if a PESEL number has not been issued.

(2) Enter as appropriate: virgin, bachelor, married, married, divorced, divorced, separated (only on a final court judgment), widow, widower.

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PART II INSTRUCTIONS AND DECLARATIONS
1. NOTICE
1. Based on Article. 4 sec. 2 of the Act of February 11, 2016 on state aid in bringing up children, the childcare benefit is granted to:
1) the mother or father, if the child lives together and is dependent on the mother or father, or
2) the actual guardian of the child (i.e. the person actually taking care of the child, if he or she applied to the guardianship court for the adoption of the child), if the child lives
together and is supported by the actual guardian, or
3) the legal guardian of the child, or
4) the director of a social welfare home.
If, according to the court decision, the child is under the alternate care of both divorced, separated or separated parents in comparable and repeated periods, the amount of the
childcare benefit is determined for each parent in the amount of half of the amount due for a given month of the benefit. educational (Article 5 (2a) of the Act). In such a case, the
application should be accompanied by a court decision confirming that the parents have alternated care over the child / children.

In the case of a child placed in a social welfare home, the childcare benefit is granted to the director of the social welfare home, unless other persons referred to in art. 4 sec. 2 of
the Act, participate in childcare and meet the conditions for receiving a child benefit (Article 5a of the Act).

2. The right to a child benefit is due to:

1) Polish citizens;
2) foreigners:
and)to which the provisions on the coordination of social security systems apply,
b) if it results from bilateral international agreements on social security binding for the Republic of Poland,
c) residing in the territory of the Republic of Poland on the basis of a temporary residence permit granted in connection with the circumstances referred to in art. 127 of the
Act of 12 December 2013 on foreigners, if they live with children in the territory of the Republic of Poland,
d) holders of a residence card with the annotation "access to the labor market", if they live with children in the territory of the Republic of Poland, with the exception of third-
country nationals who have obtained a work permit in the territory of a Member State for a period not exceeding six months, third-country nationals admitted to study
or seasonal work and third-country nationals who have the right to work on the basis of a visa,
e) residing on the territory of the Republic of Poland:
- on the basis of a temporary residence permit referred to in art. 139a paragraph. 1 or art. 139o paragraph. 1 of the Act of 12 December 2013 on foreigners, or in
- connection with the use of short-term mobility of a managerial employee, specialist or intern under the transfer within the enterprise under the conditions
specified in art. 139n paragraph. 1 of the Act of 12 December 2013 on foreigners
- if they live with children in the territory of the Republic of Poland, with the exception of foreigners who have been allowed to stay and work for a period not exceeding
nine months, unless the provisions on the coordination of social security systems or bilateral international agreements on social security provide otherwise,

f) residing on the territory of the Republic of Poland:

- on the basis of a temporary residence permit referred to in art. 151 or article. 151b of the Act of 12 December 2013 on foreigners, on the basis
- of a national visa for the purpose of conducting scientific research or development work,
- in connection with the use of short-term mobility of the researcher under the conditions specified in Art. 156b paragraph. 1 of the Act of 12 December 2013 on
foreigners,
- excluding foreigners who have been allowed to stay on the territory of the Republic of Poland for a period not exceeding six months, unless the provisions on the
coordination of social security systems or bilateral international agreements on social security provide otherwise.
The right to a child benefit is granted to the above-mentioned persons, if they reside in the territory of the Republic of Poland for the period in which they are to receive a
child benefit, unless the provisions on the coordination of social security systems or bilateral international agreements on social security provide otherwise.

3. The childcare allowance is granted until the child reaches the age of 18 (Article 4 (3) of the Act). A childcare allowance
4. is paid in the amount of PLN 500 per child per month (Article 5 (1) of the Act). A childcare allowance is not granted if:
5.
1) the child is married (Article 8 (1) (1) of the Act);
2) the child was placed in an institution that provides round-the-clock maintenance, i.e. a shelter for minors, a youth educational center, a correctional facility, a remand
center, a prison, as well as a military school or other school, if these institutions provide full support free of charge, or in foster care (Art. 8 (1) (2) of the Act);

3) an adult child has an established right to a child benefit for his / her own child (Article 8 (1) (3) of the Act);
4) a family member is entitled to a child benefit abroad or a benefit similar to a child benefit, unless the provisions on the coordination of social security systems or bilateral
international agreements on social security stipulate otherwise (Article 8 (1) (4) of the Act);

6. Granting a child benefit does not require a decision. Information on granting childcare benefit will be sent to the e-mail address provided in this application - if indicated. If the e-
mail address has not been provided, you can collect information about the childcare benefit in person at the authority examining the application. Failure to collect information
about granting a child benefit does not suspend the payment of the benefit.

2. Statements concerning the determination of the right to a child benefit

I declare, that:
- the above data is true,
- I have read the conditions entitling to a child benefit,
- for the child / children for whom I am applying for a child benefit, no child benefit is paid in this or another institution,
- the adult child / children for whom I am applying for a child benefit is not / are not entitled to a child benefit for their own child,
- the child / children for whom I am applying for the child benefit is not / are not married or has not been / have not been placed in foster care, an institution providing round-the-clock
maintenance, i.e. a youth educational center, juvenile shelter, correctional facility, detention center an investigator, a prison, as well as a military school or other school, if these
institutions provide full maintenance free of charge,
- a family member is not entitled to a child benefit for a child or a benefit similar to a child benefit abroad or the provisions on the coordination of social security systems or bilateral
international agreements on social security stipulate that the benefit granted abroad does not exclude the right to such benefit under the Act,

I am not staying or a member of my family, including the spouse or other parent of the child / children, is not staying outside the territory of the Republic of Poland (1) in
-
a country where the provisions on the coordination of social security systems apply (2),

I am staying or a member of my family, including the spouse or other parent of the child / children, resides outside the territory of the Republic of Poland (1) in a country
-
where the provisions on the coordination of social security systems apply (2).
(if checked, fill in the DETAILS OF YOUR FAMILY MEMBERS ABROAD OF YOUR FAMILY):
(1) Does not apply to travel or stay for tourism, treatment or related to the child taking up education outside the territory of the Republic of Poland.
(2) The provisions on the coordination of social security systems are applicable in: Austria, Belgium, Croatia, Denmark, Finland, France, Greece, Spain, the Netherlands, Ireland,
Luxembourg, Germany, Portugal, Sweden, Italy, Great Britain (*), Cyprus, Czech Republic, Estonia, Lithuania, Latvia, Malta, Poland, Slovakia, Slovenia, Hungary, Bulgaria, Romania,
Norway, Iceland, Liechtenstein, Switzerland.
(*) does not apply to departures after December 31, 2020.

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DETAILS OF YOUR FAMILY MEMBERS ABROAD
Provide: name, surname, PESEL number, country of residence of the family member / members abroad, including the spouse or other parent of the child / children, together
with the address of residence outside the Republic of Poland, period of stay, name and address of the employer or place of business activity abroad RP:

In the event of changes affecting the right to a child benefit, the applicant is obliged to immediately notify the municipal competent authority
providing the child benefit about these changes.
Failure to inform the municipal competent authority conducting the proceedings regarding the childcare benefit about the changes referred to
above may result in the creation of an unduly collected childcare benefit and, consequently, the need to return it together with statutory interest
for delay.

I am asking for the payment of the child benefit to the following bank account number / in the cooperative savings and credit union (1):

(1) Complete if the childcare benefit is to be paid into a bank account / credit union.

I attach the following documents to the application (the statements are also documents):

1)

2)

3)

4)

I declare that I am aware of the criminal liability for submitting a false declaration.

......................................
(City) (Date: dd / mm / yyyy) (The applicant's signature)

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