Home Tuition - Payment Claim Form 2014/2015

Riachtanais Speisialta agus Deontais Teagaisc
Rannán na Scoileanna - Airgeadas,
An Roinn Oideachais agus Scileanna
Cor na Madadh
Baile Átha Luain
Co. na hIarmhí
Special Needs and Tuition Grants
Schools Division – Financial,
Department of Education and Skills
Cornamaddy
Athlone
Co. Westmeath
PAYMENT CLAIM FORM FOR HOME TUITION PAYMENTS
FOR THE 2014.15 SCHOOL YEAR.
 The Home Tuition Grant scheme is an educational grant to cater for the cost of engaging an approved self
employed tutor to provide tuition to an approved student who cannot for a variety of reason attend or avail
of a school placement. The Home Tuition grant cannot be used, under any circumstances, for any other
purpose such as Speech and Language Therapy, Occupational Therapy, holidays, equipment , etc

Payment will issue strictly in accordance with the sanction letter issued for this scheme. Applications for
payment for unapproved periods or in respect of unapproved tutors will be refused.

By submitting this claim form for payment, both the legal guardian(s) and the approved tutor are declaring
that they have read and understood the detailed FAQ (frequently asked questions) document that is
available on the Department website - www.education.ie

The provision of Home Tuition is limited to a maximum of 5 hours tuition per child per day, Monday to Friday
between the hours of 9am to 6pm only.

Only the approved Legal Guardian(s) of the child as listed on the letter of approval issued by this
Department is/ are entitled to claim and receive the Home Tuition Grant Aid.
Payment will be issued directly into the bank account of the approved legal guardian(s) by Electronic Fund
Transfer ( EFT) only. There is no other payment option available to parents/ legal guardians.
To comply with S.I. 383 of 2009, the International Bank Account Number ( IBAN) must be supplied . In
addition a current valid tax clearance certificate in the same name of the approved legal guardian(s) must
also be supplied when this payment claim form is submitted to this Department.
Where the approved tutor is also on the primary teacher’s payroll as a permanent primary school teacher
payment will be issued directly to the tutor by this Department via the payroll upon receipt of a completed
payment claim form after each month of tuition. Parts 1 & 2 of this claim form should be submitted each
month. This method of payment does not alter the self- employed status of the approved tutor.

Funding may be issued in advance where both the approved tutor and the approved student have been
sanctioned for the full duration of the advance periods. Details of advance funding arrangements are listed in
the FAQ on the website of this Department.

Where advance payments have issued, Part 5 of the payment Claim form must be completed and submitted
in Jan 2015 and again when the scheme is completed in June 2015.
All tuition to be provided under this scheme must be to the approved student by the Tutor
approved for that child only. Tuition provided by tutors not approved for the named child or
tuition provided in a group setting will not be paid unless specifically pre -approved for
particular cases such as siblings.
The use of Tippex or other corrective fluids will make this claim form invalid and will result in this
claim form being returned to the legal guardian(s) .
Jan 2015
Part 1:
Certification by the Legal Guardian
PLEASE COMPLETE IN BLOCK CAPITALS USING A BLACK OR BLUE PEN ONLY.
This form must be completed with every application submitted seeking payment.
Name of Student: _____________________________ PPSN of this student: ___________________
Name of legal Guardian: __________________
PPSN of the legal Guardian:__________________
Contact number of legal guardian: __________________________
Email address of legal guardian: ________________________________
Expiry date of your Tax Clearance Certificate:________________ . Please enclose this certificate.
Full Name of Account: ___________________________________ (enter name of account holder)
Account Number: _________________________Bank Sort Code: __________________________
Bank Name: ______________________________________
IBAN
: ___________________________________________( Available from your bank)
The legal guardian must have withdrawal access to the nominated bank account listed above if they are
receiving the grant aid directly.
These account details MUST be provided correctly in order for payment to issue.
Name of Tutor: ____________________________________PPSN of Tutor: ________________
School Roll Number:
__________________ ( if any )
Is your teacher being paid a public services’ pension: ____________________
The tutor’s registration number from the Teaching Council of Ireland : ______________
Declaration by the Legal Guardian
I, as legal guardian of the above named student wish to confirm that:
- Having read and understood the terms and conditions of the scheme and the FAQ published by this
Department, I fully understand how the scheme operates and my responsibilities in order to receive
payment.
- I and the teacher that I have engaged have / will be in full compliance with the terms of the scheme
- I am aware that the tuition to be provided must be by the approved tutor and that group tuition is not
permitted. I also understand that the tuition must be provided in the home of the child where this is
specifically stated in the approval / sanction letters.
All the information given in this claim form is true and correct. In the event that I am overpaid my
grant aid under this scheme for any reason I will refund the Department the grant aid requested
within 7 days or upon request.
Signed : ____________________________
Date: __________________
 +353-90-648 3600
 +353-90-648 4148
 www.education.ie
 [email protected]
Jan 2015
______________________________________________________________________________
Part 2: Certification by the Teachers/ Tutors and the legal Guardian(s)
To be completed by the Legal Guardian(s) who:
-Have more than one tutor for their child who are paid at different rates of payment OR
- Do not wish to have the Home Tuition grant aid paid in advance OR
- Engage an unqualified tutor or who is not eligible for an advance payment OR
- As directed by this Department OR
- Engage tutors who are also permanent primary school teachers on the primary teacher’s payroll.
Name of Student: ________________________________ PPS number ________________________
Declaration by Teacher:
I confirm and certify that:
1. As the approved tutor of the above named student , I provided tuition to this student as outlined
in the monthly record of tuition set out below and in accordance with the terms and conditions
of the Scheme as outlined in the published Circular Letter 48 / 2014
2. No other student was present during the tuition shown below.
3. The tuition was provided by me at the following address, which is the home address of the student:
_____________________________________________________( full address must be given)
For the period: __________________ to ____________________.
Have you the written permission of your employer to engage in the
provision of Home Tuition as a self employed tutor?
Are you availing of any approved leave of absence, paid or unpaid,
from your employer while engaging in this self employment ?
Have you applied for, or are you being paid a public services’ pension
from Any government Department or public service body ?
Have you provided tuition to the above named student:
(A) Between the hours of 9am to 6pm, Monday to Friday only
(B) No other child/student has benefited from the tuition provided
to this child or Student.
Yes ______ No________
Yes _________ No________
Yes _________ No________
Yes _________ No________
List the times per day when the tuition was provided to this student
Monday Tuesday Wednesday Thursday Friday
Total hours
Week ending
tuition
/
/
/
/
/
/
/
of
/
/
/
Declaration by legal Guardian and Tutor :
We declare and confirm that all the above information is true and correct
Signature of the Approved Teacher: ______________________________ Date :___________
Signature of the approved legal guardian___________________
Date : ___________
 +353-90-648 3600
 +353-90-648 4148
 www.education.ie
 [email protected]
Jan 2015
______________________________________________________________________________
Part 3: Application for Advance Payment from the start date of the scheme to December 2014
To be completed by the legal Guardians who:
- Are seeking payment of the home tuition grant aid in advance AND
- Do not have two or more tutors on different rates of payment AND
- Are eligible for an advance payment and who have engaged qualified teachers.
Name of legal Guardian: _____________________
Name of Student: ____________________
I, the legal guardian of the above named student, wish to confirm the following:
(a) The tuition to be given to the above-named student will be in full accordance with the terms and
conditions of this Scheme as issued by the Department of Education & Skills. The tuition will not be
provided in any group setting.
(b) The tuition will be provided at : ________________________________________________
for the entire duration of the advance period which is the home address of the approved student.
(c) The approved tutor for the above named will be paid the approved hourly rate for each hour of tuition
given in accordance with the terms of the approval that issued to me by this Department. The tutor will
not receive any payment for tuition not provided.
(d) Payment received from this Department for the provision of Home Tuition will not be used for
any other purpose (including periods for which home tuition is not payable such as mid-term
breaks and school holidays/ day trips/ additional equipment )
(e) Should there be a change in circumstance of my child’s education , I will notify the Special Needs and
Tuition Grants section of the Department of Education & Skills in writing / by email to advise them of the
change and accept that the grant aid paid to me must be returned by me to this Department within
seven days. Should an overpayment occur on my claim for payments, I am aware that the Department
of Education & Skills will take steps to recover this overpayment including, but not limited to, recovery
from any other payment that may become due to me and ,if required, legal action against me.
I also am aware that I am obliged to complete and submit part 5 of this claim form in January 2015 and
also when the tuition is fully completed in June or July 2015 when the scheme closes.
Based on the above conditions and obligations that I have read and understood, I wish to apply for a
payment of the educational grant aid for the provision of Home Tuition for the period:
(A)
_________________________ until 31 December 2014.
( Date that the home tuition started or is due to start before 3rd Nov 2014)
Signed: ________________________
Legal Guardian
Date : ____________________
Declaration of Tutor:
I confirm that I am aware that:
- The Dept. of Education and Skills will issue an educational grant to the legal guardian
of the above named student.
- It is the responsibility of the legal guardian to pay my fees for the Home Tuition that I provided.
- I have the permission of my employer, where appropriate, to engage in this self-employment
- I am not on any approved leave of absence, paid or unpaid, from my employer.
- I am not allowed to provide tuition outside of the hours of 9am to 6pm. Monday to Friday
- I am aware that group tuition or group sessions are not permitted.
- I am aware that all details of this scheme are forwarded to the Revenue Commissioners
Signed: ________________________
Date: ______________________
 +353-90-648 3600
 +353-90-648 4148
 www.education.ie
 [email protected]
Jan 2015
______________________________________________________________________________
Part 4: Application for Advance Payment from January 2015 to the end of Tuition Scheme
To be completed by the legal Guardians who:
- Are seeking payment of the home tuition grant aid in advance AND
- Do not have two or more tutors on different rates of payment AND
- Are eligible for an advance payment and who have engaged qualified teachers.
Name of legal Guardian: _____________________
Name of Student: ____________________
I, the legal guardian of the above named student, wish to confirm the following:
(a) The tuition to be given to the above-named student will be in full accordance with the terms and
conditions of this Scheme as issued to me by the Department of Education & Skills.
The tuition will not be provided in any group setting.
(b) The tuition will be provided at : ________________________________________________
for the entire duration of the advance period which is the home address of the approved student.
(c) The approved tutor for the above named will be paid the approved stated hourly rate for each hour of
tuition provided in accordance with the terms of the approval that issued to me by this Department.
The tutor will not receive any payment for tuition not provided. The tutor will not receive payment for
travel or expenses.
(d) Payment received from this Department for the provision of approved Home Tuition will not be used for
any other purpose (including periods for which home tuition is not payable such as mid-term
breaks / school holidays/ day trips/ additional equipment or other non approved tutors. )
(e) Should there be a change in circumstance of my child’s education , I will notify the Special Needs and
Tuition Grants section of the Department of Education & Skills in writing / by email to advise them of the
change and accept that the grant aid paid to me must be returned by me to this Department within
seven days. Should an overpayment occur on my claim for payments, I am aware that the Department
of Education & Skills will recover this overpayment including, but not limited to, recovery from any other
payment that may become due to me and, if required, take legal action against me.
I also am aware that I am obliged to complete and submit part 5 of this claim form in January 2015 and
also when the tuition is fully completed at the end of the scheme.
Based on the above conditions and obligations that I have read and understood and agree to adhere to,
I wish to apply for a payment of the educational grant aid for the provision of Home Tuition for the period:
(A) 5th January 2015 or ___________________ to the end of my approval for the 2014/15 school year.
( When tuition started before March 2015. )
Signed: _________________________
Legal Guardian
Date : ____________________
Declaration of Tutor:
I confirm that I am aware that:
- The Dept. of Education and Skills will issue an educational grant to the legal guardian
of the above named student.
- It is the responsibility of the legal guardian to pay my fees for the Home Tuition that I provided.
- I have the permission of my employer, where appropriate, to engage in this self-employment
- I am not on any approved leave of absence, paid or unpaid, from my employer.
- I am not allowed to provide tuition outside of the hours of 9am to 6pm. Monday to Friday
- I am aware that all details of this scheme are forwarded to the Revenue Commissioners
- I am aware that group tuition or group sessions are not permitted.
Signed: ________________________
Date: ______________________
 +353-90-648 3600
 +353-90-648 4148
 www.education.ie
 [email protected]
Jan 2015
______________________________________________________________________________
Part 5: Confirmation of Home Tuition Provided
This form is to be completed:
- By parents who have received advance payments of grant aid AND
- By parents and tutors at the end of each and every advance period OR
- As directed by this Department OR
- To establish what tuition was provided during a specific period.
Declaration by legal guardian:
I am the legal guardian of the student _____________________________, and I confirm that for the
entire period of _______________________ to _________________________ the above named student:
start date )
( finish date)
1. Received the total amount of hourly tuition per week only as outlined in this claim form and tuition
was not provided in a group setting
2. The approved tutor received the full and approved hourly rate of payment for all of the tuition that was
actually provided.
3. The approved tutor was not paid for any tuition that was not provided regardless of circumstance.
4. The approved tutor did not receive payment for travel or for any expenses incurred.
5. The grant aid received in respect of the above period was not used for any other purpose except to
cater for the cost of engaging the approved tutor to provide actual tuition to my child as directed by
The Department of Education & Skills.
6. The hours provided did not exceed the daily and weekly hours approved by the Department of
Education & Skills
Signed: ____________________________ Date: __________________
Legal Guardian
Declaration by the approved Tutor:
I, the approved tutor of the above named student, confirm that for the above period:
1
I provided approved home tuition to the above named student during the approved period of tuition
2
I received my approved hourly rate of pay for each of the hours of tuition given;
3
I am not availing of any paid or unpaid leave of absence from any other employment while
engaging in this separate self employment as a tutor of home tuition.
4
I have provided the home tuition between the hours of 9am to 6pm, Monday to Friday only
5
By signing this claim form, I accept that ,the legal guardian of the student as the person who has
engaged me, has fulfilled their full obligation to me for the tuition that I have provided.
6.
I provided a total of _______ hours of Home Tuition for the entire above period
Signed : __________________________ Tutor
Date : _______________
 +353-90-648 3600
 +353-90-648 4148
 www.education.ie
 [email protected]
Jan 2015
______________________________________________________________________________
Student’s Name:______________________
Wk
Wk ending
(Friday)
1
5.9.2014
2
12.9.14
3
19.9.14
4
26.9.14
5
3.10.14
6
10.10.14
7
17.10.14
8
0
24.10.14
9
31.10.14
7.11.14
10
14.11.14
11
21.11.14
12
28.11.14
13
5.12.14
14
12.12.14
15
19.12.14
16
26.12.14
2.1.15
9.1.15
17
16.1.15
18
23.1.15
19
30.1.15
20
21
22
23
6.2.15
13.2.15
20.2.15
27.2.15
24
6.3.15
25
13.3.15
26
27
28
20.3.15
27.3.15
3.4.15
10.4.15
17.4.15
29
24.4.15
30
1.5.15
31
8.5.15
32
15.5.15
33
22.5.15
34
29.5.15
35
5.6.15
36
12.6.15
37
19.6.15
38
26.6.15
39
3.7.15
40
10.7.15
41
17.7.15
42
24.7.15
Tutor’s Name:___________________________
Total hrs worked in
week
Tuition times each day –
Start and Finish times to be provided- ( eg ) 12-2pm
Mon
Tues
Wed
Thurs
Fri
No tuition
No tuition
No tuition
No tuition
No tuition
Mid term
No tuition
No tuition
No tuition
No tuition
No tuition
No tuition
No tuition
No tuition
No tuition
No tuition
School holiday
School holiday
No tuition
No tution
No tuition
No tuition
No tuition
School holiday
No tuition
No tuition
No tuition
No tuition
No tuition
No tuition
School holiday
School holiday
No tuition
No tuition
No tuition
No tuition
No tuition
No tuition
No tuition
Signature of Tutor : ___________________________ Date : _________________
 +353-90-648 3600
 +353-90-648 4148
 www.education.ie
 [email protected]
Jan 2015
______________________________________________________________________________
Signature of Legal Guardian :___________________ Date : ___________________
Completed payment claim form(s) to be sent to:
Department of Education and Skills
Special Needs and Tuition Grants
Schools Division Financial
Cornamaddy
Athlone
Co. Westmeath.
For Official Use Only.
CLAIM:
DATES
TUTORS NAME :
NUMBER OF HOURS
RATE OF PAYMENT
AMOUNT
TO THE 19TH
DECEMBER
2014
FROM THE 5TH JAN 2015 TO
THE END OF SCHEME
PROCESSED:
Claim calculated by:
__________________
Date: _________
Claim input to FMS by: __________________
Date:_________
Claim verified and approved by: ______________ Date: _________
Secondary Approved by:___________________
Date: _________
 +353-90-648 3600
 +353-90-648 4148
 www.education.ie
 [email protected]
Jan 2015
______________________________________________________________________________
 +353-90-648 3600
 +353-90-648 4148
 www.education.ie
 [email protected]
Jan 2015
______________________________________________________________________________