Application for a Tax Credit Certificate
Please complete relevant sections in BLOCK LETTERS Personal Details
First Name Surname Date of Birth (DD/MM/YY) Address PPS No. Nationality If you have a PPS No. but cannot provide it, state: Your Birth Surname, if different Civil Status - Insert T in the relevant section below: Married or in a Civil Partnership Separated, Divorced or Dissolved Civil Partnership Insert T in the box(es) if you, your spouse or civil partner hold a ‘full’ medical card (a ‘GP only’ medical card is not a ‘full’ medical card) Self Spouse or Civil Partner Single, Widowed or Surviving Civil Partner Male Female

Form 12A

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Your Mother’s Birth Surname

Residence Details
If you lived outside the State during the last 24 months state: Date you went abroad (DD/MM/YY) Date of arrival or return to the State / / / / (DD/MM/YY) (if an Irish National) Intended duration of your stay Country of residence (i.e. number of months) prior to arrival here Permanent Temporary Are you here on a Permanent or Temporary basis? (insert T)

Employment or Pension Details
Name of Employer or Pension Company Address of Employer or Pension Company Employer’s or Pension Company’s PAYE Registered No.

Staff or Personnel No. (if any)

Occupation (e.g. Carpenter, Nurse, etc.) Full Time Part Time

Date employment commenced (DD/MM/YY) Yes Yes

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No No

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Is this your first job in Ireland? Are you related to your employer by marriage, civil partnership or otherwise? If ‘yes’, state relationship (e.g. spouse, civil partner, etc.)

Declaration
I declare that, to the best of my knowledge and belief, all the particulars given in this form are stated correctly Signature Telephone or E-mail Date (DD/MM/YY)

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1

RPC002052_EN_WB_L_2

Income from 1 January last to date
If you and/or your spouse or civil partner are/were in receipt of income