Online Application For A Tax Credit Certificate - Free Download
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Online Application For A Tax Credit Certificate
Online Application For A Tax Credit Certificate
Form 12A
Application for a Tax Credit Certicate
Please complete relevant sections in BLOCK LETTERS
Personal Details
First Name
Surname
Address
Male
Female
Date of Birth
PPS No.
Nationality
If you have a PPS No. but cannot provide it, state:
Your Birth Surname Your Mother’s Birth Surname
Single Married
Civil Status - Insert T in the relevant section below:
Divorced
Insert T in the box(es) if you, your spouse or civil partner hold a ‘full’ medical card
Self Spouse or Civil Partner
(a ‘GP only’ medical card is not a ‘full’ medical card)
Residence Details
If you lived outside Ireland during the last 24 months state:
Date you went abroad
(if an Irish National)
Date of arrival or return to Ireland
Country of residence
prior to arrival here
Intended duration of your stay
(i.e. number of years/months)
Employment or Pension Details
Employer’s or Pension
Company’s Name
Employer’s or Pension Company’s PAYE Registered No.
(available from your employer or pension company)
Date employment
commenced (DD/MM/YY)
Occupation (e.g. Carpenter, Nurse, etc.)
Staff or Personnel No. (if any)
Are you related to your employer by marriage, civil partnership or otherwise
If ‘yes’, state relationship (e.g. spouse, civil partner, son, daughter, etc.)
Yes No
Is this your rst job in Ireland
Yes No
RPC006014_EN_WB_L_1
/ /
/ /
/ /
/ /
(DD/MM/YY)
(DD/MM/YY)
(DD/MM/YY)
I declare that, to the best of my knowledge and belief, all the particulars given in this form are stated correctly
Signature
Date
Telephone or E-mail
/ /
(DD/MM/YY)
Declaration
1
State medical card expiry date (MM/YY)
/
Widowed A Surviving Civil Partner
In a Civil Partnership
A Former Civil Partner
Married but living apart
In a Civil Partnership but living apart
/
Self Spouse or Civil Partner
If you are married or in a civil partnership conrm if your spouse or civil partner resides in Ireland
If your spouse or civil partner resides abroad, state his/her country of residence
Yes No
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source: revenue.ie
Online Application For A Tax Credit Certificate
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