TAX REFUND APPLICATION

PERSONAL INFORMATION
First Name: Surname: Date of Birth: Marital Status: If married, date of marriage: How Many Children Do You Have? Date of Birth of your children: Is your spouse living in Ireland? Are you working at present? PPS No: Occupation: Nationality: Address:

Phone No: E-mail: Please indicate the tax year for which you wish to apply for a refund? 2010 Did you hold MEDICAL CARD in these years? 2011 2012 2013

INFORMATION ABOUT YOUR OR YOUR SPOUSE INCOME

Employee Income IRL Self Employed Income IRL Non Irish Income Any Other Income 2010 2011 2012 2013

TAX CREDITS AND EXPENSES

1. Were You a Single Parent during: 2. Your Occupation in: 3. Tution Fees Paid: 4. Service - Bin Charges Paid: 5. Medical Expenses Paid: (doctors fees, prescribed medicines, that have not been reimbursed by your med. Ins. Provider) 6. Does Your employer pay your Med. Insurance? 7. Trade Union Fees Paid: 8. Rent Details: Total Amoun of Rent Paid in: Period of Rent during the year: (from - to) Address of Private Rented Property: Landlords Name and Address: Landlords PPS No: Client Signature:

You may to provide your receipts to the Revenue Commissioner to support your claim. TAIN No. 73873A, Kerinstown, Killucan, Co. Westmeath, Ireland

2014

2014