Form 12a - Application For A Tax Credit Certificate
Download a blank fillable Form 12a - Application For A Tax Credit Certificate in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 12a - Application For A Tax Credit Certificate with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Form 12A
Application for a Tax Credit Certificate
Please complete relevant sections in BLOCK LETTERS
Personal Details
First Name
Male
Female
Surname
/
/
Date of Birth
(DD/MM/YY)
PPS No.
Address
Nationality
If you have a PPS No. but cannot provide it, state:
Your Birth Surname
Your Mother’s Birth Surname
Civil Status - Insert T in the relevant section below:
Single
Married
In a Civil Partnership
Widowed
A Surviving Civil Partner
Married but living apart
Divorced
A Former Civil Partner
In a Civil Partnership but living apart
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
/
/
State medical card expiry date (MM/YY)
Self
Spouse or Civil Partner
Residence Details
If you lived outside Ireland during the last 24 months state:
Date you went abroad
(DD/MM/YY)
Date of arrival or return to Ireland
/
/
/
/
(DD/MM/YY)
(if an Irish National)
Country of residence
Intended duration of your stay
prior to arrival here
(i.e. number of years/months)
If you are married or in a civil partnership confirm if your spouse or civil partner resides in Ireland
Yes
No
If your spouse or civil partner resides abroad, state his/her country of residence
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)
Staff or Personnel No. (if any)
Date employment
/
/
Occupation (e.g. Carpenter, Nurse, etc.)
commenced (DD/MM/YY)
Is this your first job in Ireland?
Yes
No
Are you related to your employer by marriage, civil partnership or otherwise?
Yes
No
If ‘yes’, state relationship (e.g. spouse, civil partner, son, daughter, etc.)
Declaration
I declare that, to the best of my knowledge and belief, all the particulars given in this form are stated correctly
Date
/
/
Signature
(DD/MM/YY)
Telephone or E-mail
1
RPC006014_EN_WB_L_1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial