HMRC Tax Declaration

Part A - Your personal details

Title:

Full name:

Full residential address:

Phone number:

If you have a tax adviser, please give details.

Adviser’s name:

Adviser’s address:

Phone number:

Fax number:

Reference/contact name:

Please give:

Your date of birth:

Your nationality:

Your tax reference number in your country of residence:

If you have at any time lived in the UK, please give:

Your UK National Insurance Number:

and your exact date of departure from the UK.

Departure date:

If you have never lived in the UK, please tick here:

Part B - Please answer the following questions

1. In which country are you resident for tax purposes?

2. Have you always lived in that country? Yes No

If No, on what date did you begin to live there permanently?

Become liable to pay tax there?

3. Since you left the UK, have you or your spouse/civil partner continued to own or rent a property in the UK? Yes No

If yes, provide details on a separate sheet.

4. How many days did you spend in the UK during the period from the date you left the UK to the following 5 April?

Days:

Each UK tax year since the date you left the UK to live abroad:

Tax year to 5 April 20 Days

Tax year to 5 April 20 Days

Tax year to 5 April 20 Days

5. Have you been in the UK during the past four years for 183 days or more in any one tax year? Yes No

91 days or more a tax year on average? Yes No

6. Have you been not resident for tax purposes in the country shown in answer to question 1 in any one of that country's previous four tax years? Yes No

7. Are you engaged in any trade or business in the UK, or do you perform independent personal services from a fixed base situated in the UK? Yes No

8. Do you receive any special tax benefits in your country of residence which mean that you pay no tax, or reduced tax, there on the UK income shown on this form? Yes No

9. Do the tax authorities in your country of residence tax you only on the amount you remit to or receive there? Yes No

10. Do you remit to your country of residence all of the income from the source(s) you show in this form? Yes No

If no, how much do you remit? £

Part C - Relief at source from UK income tax

C.1 UK State Pension or Incapacity Benefit

UK State Pension Date on which payments began:

UK Incapacity Benefit Date on which payments began:

C.2 Work pensions and/or purchased annuities

Columns: Full description of income and name/address of UK payer; Payer's reference number; Date payments began.

C.3 Interest

Please do not show bank or building society interest here.

C.4 Royalties

Are you the originator of the work or product that has been licensed to the UK? Yes No

Part D - UK income tax taken off payments already received

Totals - amount before UK tax: £

Totals - amount of UK tax taken off: £

Part E - Authority to make repayment to a nominee

Complete this part if you want us to make the repayment to a nominee.

Name of person, bank or building society:

Address of person, bank or building society:

Postal code:

Account holder's name:

Nominee's reference number:

Part F - Declaration

I am beneficially entitled to the income from the source(s) included in this form or otherwise meet the conditions for relief in the double taxation treaty.

The information I have given in this application/claim is correct and complete to the best of my knowledge and belief.

1. I apply for relief at source from UK income tax and undertake to tell the Centre for Non-Residents if there is any change to the information given in this form.

2. I claim repayment of UK income tax and:

(a) have worked out that the amount repayable to me is £

(b) want the Centre for Non-Residents to work out the amount repayable to me.

For official use by HM Revenue & Customs

Authorised: