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12 Form 12A Application for a Certificate of Tax Credits and Standard Rate Cut-Off Point Please complete relevant sections in BLOCK CAPITALS. Read the Form 12A Help Sheet attached before completing this form. Use this application form if commencing your first employment in the State, or if you are recommencing employment following a period of unemployment A. Personal Details Title Mr Ms Mrs Miss Other Surname (Family Name) Address First Name Date of Birth Nationality PPS Number DD / MM / YY (See Note 1 on help sheet) If you have a PPS No. BUT cannot provide it, give: Your Birth Surname if different Your mother s birth Surname B. Residence Details (see note 2 on Help Sheet) If you lived outside the State during the last 24 months please state: Date you went abroad DD / MM / YY Date of arrival/return to (if an Irish National) the State DD / MM / YY Country of residence prior to Intended duration of your stay arrival here here (i.e. number of months/years) Are you here on a Permanent/Temporary Basis C. Employment/Pension Details (If you have any difficulty with these questions, ask your employer for assistance) Name of Employer/Pension Payer Address of Employer Employer s Trade or Profession Employer s PAYE Registered No. Date employment commenced DD / MM / YY Tel: Unit No. (if known) Personnel No. (if any) Occupation (e.g. Carpenter, Nurse etc) Full-time Part-time Rate of Pay and frequency Weekly Fortnightly Monthly Do you have Benefits from your employer (e.g. company car, vouchers, loan etc.) Yes No If yes give details on a separate sheet Are you related to your employer by marriage or otherwise? Yes No If yes, state relationship (e.g. son, daughter, spouse etc.) D. Income from 1st January last to date If in receipt of income from the Department of Social, Community & Family Affairs, please state the following: Type of payment (e.g. Unemployment Benefit, Social Welfare Pension, Disability Benefit, One-Parent Family Payment etc.) Date payment commenced DD / MM / YY Weekly amount Date payment ceased, if ceased If previously employed Name & Address of last employer Date this employment ceased DD / MM DD / MM / YY / YY Did you receive Form P45 on cessation Attach Form P45 if in your possession Yes No

13 E. Details of any other income (e.g. Share Options, US/UK Pensions, Rents, Interest, Dividends, Farming, Self-Employment Income, etc.) Description of Income Annual Amount (Self) Annual Amount (Spouse) F. Claim for Tax Credits & Reliefs Please tick the tax credits you wish to claim Single Persons Tax Credit *Dependent Relative Tax Credit *Incapacitated Child Tax Credit Married Persons Tax Credit *Widowed Parent Tax Credit Age Tax Credit if aged over 65 Widowed Persons Tax Credit *Blind Persons Tax Credit *Rent Relief *One Parent Family Tax Credit *Home Carer s Tax Credit *Tuition Fees Annual Trade Union Subcriptions Services Charges Annual Payment *Relief for Care of an Incapacitated Individual Items marked with an * may require more detailed information and you will be contacted in relation to your claim G. Spouse s Details If Widowed and this is your first claim for Widowed Persons Tax Credit state Spouse s date of death Spouse s PPS No. If Separated/Divorced and this is your first tax claim as a separated person state Date of Separation/Divorce DD / MM / YY (Attach a copy of any legal documents covering same) If Married and you are claiming Married Persons Tax Credit state spouse s Name Country of Residence If spouse is resident in the State give details of spouse s income Name and Address of Spouse s Employer Spouse s PPS No. Nationality Date of Birth Spouse s PPS No. Rate of Pay and frequency Weekly Fortnightly Monthly Other Sources of Income If you have married in the last 2 years state date of marriage DECLARATION I declare that all the information given by me on this form is correct to the best of my knowledge and belief. Signature Daytime Telephone No. DD / MM / YY Please complete and return this to the address below as soon as possible. If no address shown ask your employer for the postal address of your tax office Date DD / MM / YY DD / MM / YY DD / MM / YY When returning this form, use any envelope and write FREEPOST over this address Office Hours Monday - Friday 9.30 a.m p.m. If you need further information on any point, please contact the tax office at LoCall

14 Detach and Keep this Help Sheet Form 12A Help Sheet General Information on completing Form 12A and applying for a Certificate of Tax Credits and Standard Rate Cut-Off Point Complete Form 12A to apply for your Certificate of Tax Credits if any of the following applies: you are starting your first employment in the State you are a national of another country living in Ireland and are starting your first employment in the State you are recommencing employment following a period of unemployment. To complete this form you need your Personal Public Service Number (PPS No.) your Employer s PAYE Registration Number - ask your wages section your personnel / works number - ask your wages section if this is relevant Note 1: How do I obtain my Personal Public Service Number (PPS No.)? Your PPS No. can be obtained from the Department of Social, Community and Family Affairs. You must first register with a Social Welfare Local Office of the Department of Social, Community and Family Affairs to obtain your PPS No. before applying for your Certificate of Tax Credits. In general, Irish nationals born before 1971 who are not already registered for tax in the State, and nationals from other countries coming to work here will not have a PPS No. and must obtain their PPS No. from a Social Welfare Local Office. Leaflet SW 100 Personal Public Service Number issued by the Department of Social, Community and Family Affairs gives further information on how to register for your PPS No. The leaflet is available from your Social Welfare Local Office and on the Department s website at Irish Nationals should have a PPS No. if they: were born in the State after 1971 registered for tax since 1979 are / were in receipt of Social Welfare Benefit payment were issued with a Social Services Card. The tax office may be able to trace your PPS No. where you have been allocated one and you cannot locate it. Where they are unable to trace your number, Form 12A will be returned to you and you must apply to a Social Welfare Local Office for the number. [If your form is submitted to the tax office without your PPS No. it may lead to a delay in issuing your Certificate Of Tax Credits And Standard Rate Cut-Off Point.] Note 2: General Information for individuals coming to live in Ireland. Revenue s publications RES 2 Coming to live in Ireland give general information on our Residence rules. Residence status and Domicile, influence the extent to which an individual is liable to tax in Ireland and their entitlement to tax credits. It is important to tell the tax office what your intentions are with regard to residing in Ireland. Irish nationals returning to work in Ireland and nationals from other countries coming to work in Ireland, must answer the residence questions at Section B on Form 12A. In this section, state if you have moved / returned to live here on a permanent basis. Alternatively, if you are living here for a temporary period, or for temporary holiday work, state the expected duration of your stay. This information will assist the tax office in determining your entitlements.

15 Note 3: What is Emergency Tax? [It is very important that you obtain your Certificate of Tax Credits and Standard Rate Cut-Off Point, as quickly as possible to avoid Emergency Tax deductions.] If your employer does not hold a Certificate of Tax Credits and Standard Rate Cut-Off Point for you, tax will be deducted at Emergency Rates. This means that for the first 4 weeks of employment, tax is calculated on the gross pay at the standard rate of tax and reduced by a tax credit of 1/52 of the personal tax credit, if paid weekly, or 1/12 of the personal tax credit, if paid monthly. For weeks 5 to 8, tax is calculated on the gross pay at the standard rate of tax without any tax credit. From week 9, tax is calculated on the gross pay at the higher rate of tax. Emergency tax results in excessive tax deductions. It is in your interest to obtain your Certificate of Tax Credits and Standard Rate Cut-Off Point and avoid having too much tax deducted. Note 4: How do I apply for my Certificate of Tax Credits and Standard Rate Cut-Off Point? Fill in the appropriate sections on form 12A. Your claim will be processed promptly if you quote your Personal Public Service Number (PPS No.), your employer s PAYE Registration number, and you complete all relevant sections of the form. Send the completed form to the Tax Office dealing with your employer or call in person with the form to any of the tax offices listed in Information Leaflet IT 1. Both you and your employer will be notified of your tax credit and standard rate cut-off point. Your employer will then make the necessary tax deductions from your salary. Further Information More information on the tax credit system are contained in the following Leaflets and Forms: IT 1 IT 2 Tax Credits Reliefs and Tax Rates Taxation of Married Couples Form RES 2 - Coming to Live in Ireland Form Rent 1 - Claim for Rent Relief on Private Rented Accommodation Form OP1 - One-Parent Family Tax Credit CG13 Mortgage Interest (Tax Relief at source) These and other leaflets and forms are available on Revenue s website at from Revenue Forms and Leaflets Service, Telephone number at LoCall or from any tax office. What is a Form P45? When you leave your employment, your employer must give you a form P45. Your P45 shows your pay, tax and PRSI deductions from the start of the tax year to the day you leave your employment. You need your P45 to give to your next employer, to claim a tax refund if unemployed, or if claiming Social Welfare benefits. What is a Form P50? If you are unemployed during the tax year you may be entitled to a refund of tax. Make your first application to your tax office on Form P50. What is a Form P60? If in employment at the end of the tax year your employer must give you a Form P60. Your P60 shows your total pay, tax and PRSI deducted during the tax year.

16 FIRST CLAIM FOR TAX REPAYMENT DURING UNEMPLOYMENT Please read the INFORMATION NOTES overleaf BEFORE completing this form. N.B. Form P45 Parts 2& 3 MUST accompany this claim NAME and ADDRESS (Block Capitals) PPS Number Employer Number Unit Number Date of Cessation Of Employment Day Month Year Refer to your form P45 for answers to above Employer Name AMOUNT OF INCOME RECEIVED BY YOU SINCE THE DATE YOU BECAME UNEMPLOYED Tick ( ) the appropriate box below Unemployment Benefit Other Social Welfare Income - please state type: Disability Benefit In the case of the above: Please state the date this income started Gross weekly amount Number of children included in your claim Unemployment Assistance is not taxable. If you are in receipt of U/A, please indicate by ticking this box Other Income - Please state source of income and gross amount received to date 1. Do you intend to resume employment in Ireland before 31 December next? Y/N If the answer is no, state reason: If resuming education, state name of school/college 2. Are you making this claim on the basis that you are going abroad? Y/N If answer is yes please state (a) country of destination, (b) intended departure date (c) duration of stay abroad 3. Do you intend to take up employment abroad? Y/N 4. Address abroad for correspondence 5. If you wish to have any repayment that may be due to you lodged to your Bank Account please tick ( ) and complete the following details: (The cheque will then be posted to your bank for lodgement.) Name/Address/ Bank Sort Code - - Branch of Bank Account Number DECLARATION WHICH MUST BE SIGNED I declare that I am unemployed and that all particulars in this form are correct to the best of my knowledge and belief. Signature: Date: / / Tel No. Form P50 A person who knowingly makes a false statement for the purpose of obtaining repayment of income tax is liable to heavy penalties

17 ALL SECTIONS AND THE DECLARATION MUST BE COMPLETED IN ALL CASES (Where this form is not completed in full, it may be necessary to return it to you which may delay processing your claim.) 1. Am I entitled to a tax refund? If tax has been deducted from your pay since 1 January and you are now unemployed you may be entitled to a tax refund. 2. When do I apply for a refund? You should wait a minimum of four weeks from the date you became unemployed before you apply for a tax refund. If however you are in receipt of any taxable sources of income (which would include taxable income from the Department of Social & Family Affairs) you should wait a minimum of eight weeks. 3. How much tax is refunded? If you are entitled to a tax refund the amount of the refund will depend on: the length of time you have been unemployed the amount of tax you have paid whether you have arrears of tax. 4. How do I apply? Complete the form overleaf and send it to your Regional Revenue Office together with: Form P45 (Parts 2 & 3) given to you by your last employer, AND Where applicable, supporting documentation in respect of tax deducted from any casual earnings or any other source of income returned overleaf. 5. What happens next? Your Revenue Office will send you details of the refund (if any). Certain amounts payable to you from the Department of Social & Family Affairs may not be liable, in full, to income tax. In calculating your repayment, Revenue will exclude any amounts which are not taxable. Further Information You can get further information by phoning (within ROI only) your Regional Revenue Office, the LoCall number for which is listed below: Border Midlands West Region Cavan, Donegal, Galway, Leitrim, Longford, Louth, Mayo, Monaghan, Offaly, Roscommon, Sligo, Westmeath Dublin Region Dublin (City and County) East & South East Region Carlow, Kildare, Kilkenny, Laois, Meath, Tipperary, Waterford, Wexford, Wicklow South West Region Clare, Cork, Kerry, Limerick If you are calling from outside the Republic of Ireland, please telephone (1) Alternatively, you can visit the Revenue website at

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