First Name * * indicates mandatory field Surname * Address 1 * Address 2 * Address 3 * Address 4 Address 5 Phone Number * E-mail Address * Date of Birth * PPS Number * Nationality -Select Country-AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, the former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVienamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe * Date of arrival * Date of departure * Marital Status -Select Marital Status-SingleMarriedSeparatedDivorcedWidowed * Spouses Name * Spouses PPS Number * Spouses Date of Birth * Were you married in the last four years? NoYes * Date of marriage * Spouses Nationality -Select Country-AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, the former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVienamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe * Is spouse living in Ireland? NoYes * Spouses Date of arrival * Spouses Date of departure * Spouses Name * Spouses PPS Number * Spouses Date of Birth * Date divorced * Date widowed * Number of Children under 18 years of age * 012345678 Tests Are you claiming single parent allowance NoYes Are you living with a Partner? NoYes test

Years in which refund is being claimed? 2011 2010 2009 2008 You must select at least one year to complete this application form. Complete questions will only appear if at least one year is selected Select your Industry or Employment Category: None of TheseActor (freelance)Airline IndustryBuilders & Related TradesCarpentry & Joinery TradeCosmetologistDockerDriving InstructorsEducation (Primary & 2nd Level)Education (Third Level)Engineer - EircomEngineering & ElectricalFishingHealth ServicesHospital - I Launder Uniform SuppliedHospital - I Supply & Launder UniformHospital Launders Uniform & I SupplyHospital Supplies & Launders UniformHotel and Bar TradeJournalismMining IndustryMotor Repair - I Supply Tools/OverallsMotor Repair - Tools/Overalls SuppliedOccupational TherapistPhysiotherapistPrintingPublic Sector - Civil ServicePublic Sector - Local AuthorityPublic Sector - Semi-State BodyRacing IndustryReligiousRetailSheet Metal WorkerShipping - British Merchant NavyShipping - Mercantile Marine / Irish ShipsValuersVetinary Profession: Have you paid bin / water charges? NoYes You can contact your waste provider for receipts of bin charges paid 2011 Tax Year: Name of bin service provider: Amount paid in 2010: € 2010 Tax Year: Name of bin service provider: Amount paid in 2009: € 2009 Tax Year: Name of bin service provider: Amount paid in 2008: € 2008 Tax Year: Name of bin service provider: Amount paid in 2007: € Note applicable charges refer to the amount paid in the previous calendar year e.g. for 2011 you need to supply 2010 information. Are you or have you been a member of a trade union? NoYes 2011 Tax Year: Trade Union Name: Fees: € 2010 Tax Year: Trade Union Name: Fees: € 2009 Tax Year: Trade Union Name: Fees: € 2008 Tax Year: Trade Union Name: Fees: € Have you paid tuition fees at college / university? NoYes You don't have to have completed the course yourself, once you have paid the fees then you are entitled to the refund. 2011 Tax Year: (Add another course) College & Course Name: Fees: € (Delete this course) 2010 Tax Year: (Add another course) College & Course Name: Fees: € (Delete this course) 2009 Tax Year: (Add another course) College & Course Name: Fees: € (Delete this course) 2008 Tax Year: (Add another course) College & Course Name: Fees: € (Delete this course) Have you paid rent for private accommodation in Ireland? NoYes Number of rental addresses for all years being claimed 01234 Have you incurred medical expenses? NoYes Doctors and prescription details can be obtained by contacting your doctor and chemist. A summary for the relevant years can be requested. 2011 2010 2009 2008 Doctor / Consultant Services € € € € Prescribed Drugs / Medicines € € € € Hospital Treatment / Maintenance € € € € Nursing Home Expenses € € € € Other Medical Expenses € € € € Amount Received from insurance provider in respect of the above medical expenses € € € € Amount Received from other sources e.g. HSE or an insurance claim in respect of the above medical expenses € € € € Has your employer paid any part of your medical insurance
(e.g.; VHI, Quinn healthcare or Hibernian Aviva) NoYes 2011 2010 2009 2008 Gross amount paid in year € € € € Have you incurred non-routine dental expenses in the past four years? NoYes 2011 2010 2009 2008 Crowns € € € € Veneers / Etched Fillings € € € € Endodontics / Root Canal € € € € Bridgework € € € € Other Dental Expenses € € € € Would you like Taxpal to check for PRSI / Health Levy / Income Levy refunds. NoYes Have you had a FULL medical card in any of the following tax years: If you have a FULL medical card then you should be exempt from paying the health levy or Income levy. 2011 Tax Year: NoYes 2010 Tax Year: NoYes 2009 Tax Year: NoYes 2008 Tax Year: NoYes

Have you earned any other income in any of the applicable years? NoYes This refers to any other income that has been earned outside your PAYE income, eg; rental income, self employed income. 2011 Tax Year: Description Amount: € 2010 Tax Year: Description Amount: € 2009 Tax Year: Description Amount: € 2008 Tax Year: Description Amount: €

How many employers did you have in the tax year? 2011 Tax Year: 01234 2010 Tax Year: 01234 2009 Tax Year: 01234 2008 Tax Year: 01234

Did you have a break of employment in any of the years being claimed? NoYes 2011 Tax Year: NoYes 2010 Tax Year: NoYes 2009 Tax Year: NoYes 2008 Tax Year: NoYes

Do you or your spouse stay at home to look after a dependant? NoYes (Dependant = child, person aged 65yrs or over or person mentally or physically incapacitated) Do you have an incapacitated child? NoYes (Incapacitated Child = Child mentally or physically incapacitated from maintaining themselves.) Do you maintain a dependant relative? NoYes (to qualify, must maintain at own expense a relative who is incapacitated by old age/infirmity from maintaining themselves.) Do you employ a Carer? NoYes (applies to a family member who employs a person to care for an incapacitated relative.) Do any of the following tax credits apply? Blind Tax Credit NoYes Guide Dog Allowance NoYes

How would you like to receive your refund payment from the Revenue Commissioners? ChequeBank Transfer Bank Name: * Taxpal uses a secure SSC connection so all details are private and secure Bank Address: * Account Name: * Sort Code: * Account Number: * Application form not complete - click SAVE and return later via 'customer login' on home page.
Application form compete - click Next to proceed to Stage 6 for processing.

How would you like to proceed with signing your forms? -Select Processing Method-Print NowPost forms to me We will send you the following details within 5 working days which you must sign and return to us:

• Copy of your completed application form
• Revenue Declaration form
• Terms and conditions

In addition please send in

• Relevant years P60 and 2009 Income Levy Statement (P60's are required to check for PRSI and health levy refunds)
• Relevant years P60 and 2009 Income Levy Statement for spouse if applicable (P60's are required to check for PRSI and health levy refunds).
• Bank Details Form, if not already provided above
• Form Med 2 (if applicable)
• Single Parent Forms (If applicable)

To track how your application is progressing please login into your account with your username and password which will have been sent to you by email. Please download the following forms to print. To progress your application, simply sign and return these forms to taxpal.

My Completed Tax Refund Application Form Revenue Declaration Form Taxpal Terms & Conditions Checklist Form Med 2 OP1 - Claim for One-Parent Family

To track how your application is progressing please login into your account with your username and password which will have been sent to you by email. Please confirm that you would like to process your application Proceed with Stage 6 if application form is complete. If not complete, return to Stage 5 for saving.