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Form preview Template hmrc tax declaration... The Digest is available electronically from www. hmrc.gov.uk/cnr or on paper from the address in Note 6. 2. Purpose of the form DT/Individual source from UK income tax on pensions purchased annuities royalties and interest paid from sources in the UK. Specific forms are available for residents of certain countries - please see www. hmrc.gov.uk/cnr Please use the DT/Individual Notes to help you fill in this form give all the details asked for in the form and sign the declaration in Part F send the form to the taxation authorities of your country of residence. Form DT/Individual Double Taxation treaty relief APPLICATION for relief at source from United Kingdom income tax and CLAIM to repayment of United Kingdom income tax For use by an INDIVIDUAL resident of a country with which the UK has a double taxation treaty that provides for relief from UK income tax on pensions purchased annuities interest or royalties arising in the UK. See note 4 in the DT/Individual Notes. If you need help or more information please write to HM Revenue Customs - Centre for Non-Residents Fitz Roy House PO Box 46 Nottingham England NG2 1BD. Or phone us between 07. 30 and 17. 00 Monday to Friday 44 151 210 2222 if calling from outside the UK or 0845 070 0040 if calling from the UK. Part A Your personal details Mr Mrs Ms Miss or other title Full name If you have a tax adviser please give details. See DT/Individual Note 5. Adviser s name Full residential address Adviser s address Phone number Fax number Enter a phone number where we can contact you. This may help us deal with your completed form more quickly. Please give Your date of birth Day Month Year Your nationality Reference/contact name if any 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. Your tax reference number in your country of residence If you have never lived in the UK please here o For use by the taxation authorities in the country of residence Please complete this part and add your official stamp* You may wish to take a copy of the form for your records. If your procedure is to send the form direct to the UK taxation authority the address to which to send it is HM Revenue Customs - Centre for Non-Residents Fitz Roy House PO Box 46 Nottingham England NG2 1BD I certify that Official Stamp is resident in within the meaning of the double taxation treaty between the United Kingdom and this country if appropriate o and subject to this country s tax on the income shown in this form the amount of remitted to this country. Signature Date W Part B Please answer the following questions 1 In which country are you resident for tax purposes where appropriate Yes o 2 Have you always lived in that country If No on what date did you begin to live there permanently become liable to pay tax there No o 3 Since you left the UK have you or if you are married or have formed a civil partnership your spouse or civil partner continued to own or rent a property in the UK If Yes give on a separate sheet the address of the property.

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