APPLICATION FORM. Attach any supporting documents to the completed pack before ing to WHAT HAPPENS NEXT

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1 APPLICATION FORM IT S QUICK AND EASY TO GET YOUR IRISH TAX REFUND. JUST FOLLOW THE STEPS BELOW or Complete the pack in BLOCK CAPITALS including as much information as possible. Scan or make photos of the completed pack Attach any supporting documents to the completed pack before ing to irishdocuments@taxback.com, Post to Taxback.com, IDA Business and Technology Park, Ring Road, Kilkenny. Please, only send a copy of your receipts and supporting documents as we do not store or return original documents received. WHAT HAPPENS NEXT Once we receive your information, we ll review it and: a) call you to confirm any outstanding information, or b) if no additional information is required, will send a request to Revenue to register us as your tax agent and get access to you pay and tax details. This procedure can take between 1-2 weeks. Having access to your pay and tax details our specialist review your case and: a) call you to confirm the estimated refund amount, or b) contact you for additional information that can help us maximise your refund estimation As soon as your application is complete and you provide approval, we will submit it to Revenue. Assuming all is in order, we can expect the claim to be processed within 2 to 6 weeks. During this time our payments team will contact you to organise payment options for you, so that we can transfer the payment into your account as soon as it has been received PERSONAL INFORMATION First Name Surname Nationality* PPS No Date of Birth / / Marital status: Single Married Divorced Separated Widowed Registered Civil Partnership Please indicate your basis of assessment: Jointly Assessed Separately Assessed Single Treatment Name of s Date of Birth / / Maiden Name Nationality of * s PPS No Date of Marriage / / How did you hear of our service? Phone Number Home Address * If you or your spouse are a Non EU citizen, please include a copy of Photo Id (such as Passport, Driving License or National ID Card) and information regarding permission to work in Ireland (please supply copy of visa or work permit, if relevant). TAX YEARS Are you working in Ireland at present? Yes No Is your spouse working in Ireland at present? Yes No tax year Tick the years you wish to apply for a refund Please indicate if you or your spouse applied for these tax refunds before? If yes, amount received Amount received by spouse Credits, Reliefs, Expenses Claimed (if known) Have you or your spouse received any correspondence from the Revenue Commissioners? Yes No If yes, please send us relevant copies by 1

2 RESIDENCY QUESTIONS Time outside Ireland If relevant, please state the approximate number of full days you and your spouse spent outside Ireland If you have spent significant time in another country or have just moved here we need to know more about your residency situation: Please provide (where relevant): initial entry date / / and exit/proposed exit date / / initial entry date / / and exit/proposed exit date / / Working Abroad If you or your spouse have worked abroad in the last 4 years and paid any tax there please provide details Country Date started work / / Date finished work / / Country Date started work / / Date finished work / / INCOME SECTION If you received income from the following sources, please tick where appropriate Employment Income Jobseekers Benefits Other Social Welfare Payments Did you or your spouse had any other sources of income (eg rental income,dividend income, deposit interest, foreign income etc.)? 2010 Yes No Yes No Yes No 2011 Yes No Yes No Yes No 2012 Yes No Yes No Yes No 2013 Yes No Yes No Yes No 2014 Yes No Yes No Yes No How many employers did you have in the year? What was your primary occupation each year? If applicable, please state what the other social welfare payment(s) related to r spouse Note: in order to expedite your application, please send any payment Form(s) you may have in respect of your employment - eg P60/P45/ IL/USC certificates to irishdocuments@taxback.com. If you don t have them don t worry, you can still send your application without them. 2

3 TAX CREDITS AND EXPENSES Tax credits and expenses may significantly increase your refund. Rental Credit: Please provide details for each tenancy in the last 4 years. If you only started renting after 07/12/2010 you will not be eligible for Rent Tax Credit Tenancy 1 Tenancy start date / / Tenancy finish date / / Monthly rent paid Landlord/ Estate agent name Landlord s PPS Number Landlord/ Estate agent address Address of rented property Tenancy 2 Tenancy start date / / Tenancy finish date / / Monthly rent paid Landlord/ Estate agent name Landlord s PPS Number Landlord/ Estate agent address Address of rented property Tenancy 3 Tenancy start date / / Tenancy finish date / / Monthly rent paid Landlord/ Estate agent name Landlord s PPS Number Landlord/ Estate agent address Address of rented property Note: in case you had more then 3 tenancies in the last 4 years, please provide details on different page Were you a full medical card holder during? If yes, please provide the number Were your spouse a full medical card holder during? If yes, please provide the number Have you paid service charges (i.e. bin charges) (Service charges are based on the previous tax year spend.) n/a n/a n/a n/a n/a n/a Did you pay any union fees in 2010? Yes No Yes No For any of the below expenses and credits you wish to claim, please attach receipts. Tuition fees to any educational institute (paid for yourself or a dependant relative) Name of the educational institute, course name and type (part time/full time) Receipts available Receipts available Medical expenses incurred (i.e.doctors fees, prescribed medicines, diagnostic procedures, physiotherapy, a&e etc) that have not been reimbursed by your medical insurance provider during Receipts available Receipts available 3

4 Non routine dental expenses incurred (eg root canals, crowns, orthodontic treatments) Med 2 Form available Med 2 Form available Contribution made by employer to a medical insurance provider on your behalf as a benefit-in-kind Statement available Statement available Pension contributions made by you or your spouse in addition to payments made through payroll Receipts or annual statement available Receipts or annual statement available IMPORTANT NOTE: We will need evidence (ie receipts) to support your claim. If you cannot gather this information, you can avail of the taxback.com document retrieval service Don t hold up your Application: If you cannot send receipts with this pack, don t worry, while you get your receipts together, we can move forward with the application and can request authorisation to view your pay and tax details and then provide you with an estimation. Alternatively you can use the taxback.com document Retrieval Service. Were you or your spouse a single parent during (the children must stay with you at least part of the year and you should not be living with a partner) Were you or your spouse a stay-at-home parent during How many children did you have in the tax year? Were you or your spouse taking care of a dependent relative? Please provide separately the Name, PPS and DOB of the child/children or dependent relative as it will will enable to claim additional credits and increase your refund. Other information that might be relevant for application: 4

5 DECLARATION TO THE REVENUE COMMISSIONERS OF (AUTHORISATION FORM PAYE A2) 1. Authorisation to act as agent I, (first name, surname), Date of Birth / /, PPS Number, Date of Birth / /, PPS Number (first name, surname), authorise taxback.com, TAIN 71354M, with an address at IDA Business & Technology Park, Ring Road, Kilkenny. to act as my agent in dealing with all aspects of the filing of my Irish income tax return, including the submission of refund or credit claims, allowances or reliefs. I confirm that this authorisation will remain in force until Revenue is formally notified of its cessation by either myself or taxback.com. 2. Authorisation for Agent to receive refunds on behalf of client I authorise the transfer of any refund or repayment due to me by the Revenue Commissioners by electronic funds transfer to the following bank account which is held by taxback.com: Bank: AIB IBAN: IE 77AIBK Name of Account Holder: taxback.com BIC: AIBKIE2D I understand that any refund made by the Revenue Commissioners to my agent, taxback.com, on my behalf is refunded in a similar manner as if same were being refunded directly to me and that once the refund is transferred into the bank account nominated by me I have no further call upon the Revenue Commissioners in respect of same. I understand that taxback.com is acting as my agent and is solely responsible to me in respect of any refund received by them on my behalf. I further understand that my agent taxback. com is an independent entity and that the Revenue Commissioners make no endorsement of my agent or any such agency and cannot accept any responsibility whatsoever for problems encountered by me in dealing with them. I understand and agree that taxback.com will input its own bank account details on the Revenue record for the duration of this mandate and will remove these details on the cessation of the mandate. I confirm that I am aware of, and agree to, the payment of the fees charged by taxback.com in respect of the services carried out on my behalf and that this fee will be deducted from any amount refunded by Revenue and that the balance of this amount will be paid to me. 3. Terms and Conditions of Authorisation I understand that Tax law provides for both civil penalties and criminal sanctions for the failure to make a return, the making of a false return, facilitating the making of a false return, or claiming tax credits, allowances or reliefs which are not due. I confirm that I will provide the necessary documentation to taxback.com to support any refund, credit claims or claims for allowances and reliefs made to Revenue on my behalf by taxback.com. I confirm that I will provide details of all my sources of income to taxback.com I understand that taxback.com is required to retain a copy of all documentation relating to any refund or credit or allowance or relief claimed by the agent on my behalf and that the agent will be required to produce same to Revenue upon request. Customer Name Name CUSTOMER SIGNATURE SPOUSE SIGNATURE taxback.com Date Date Date NOTE: taxback.com is a trading name of Taxback Inc., Chicago US 5

6 CUSTOMER AGREEMENT The terms and conditions below refer to the taxback.com tax returns and refund services. Please read these points in full and ensure you understand them before signing. I confirm that: 1. I understand that taxback.com is a trading name for the services of Taxback Inc., Chicago, USA,and hereby contract with Taxback Inc. to carry out the services described herewith. 2. I understand that Taxback Inc will utilise its parent company Taxback and its subsidiary and affiliate companies to gather information regarding the services where necessary and that the contract remains with Taxback Inc for the duration of the service. 3. I have signed the Customer Declaration to authorise Taxback. Inc, and / or its subsidiary undertakings trading as taxback.com and referred to hereafter as the Agent, to prepare this tax return and represent me before the Revenue Commissioners of Ireland and the Department of Social and Family Affairs, Ireland). 4. I commit that I will provide the necessary documentation to taxback.com to support any refund claim made to the Revenue Commissioners on my behalf. 5. I authorise taxback.com to be my tax agent to represent me in all communication, submission and correspondence with the Revenue Commissioners of Ireland and the Department of Social and Family Affairs, Ireland for the tax years specified by me. 6. I authorise taxback.com to: a. Review my earnings, taxes paid, tax credits, expenses, and allowances due and all other specific areas relating to my tax returns and to submit my tax return on my behalf to the Revenue Commissioners of Ireland. b. Receive all correspondence about my tax affairs and respond as appropriate. c. Organise the payment of taxes due to me or payment of any monies owed by me to the Revenue Commissioners and from the Department of Social and Family Affairs. d. Receive any refunds due from the Revenue Commissioners to me by cheque to the taxback.com offices or by bank transfer from the Revenue Commissioners into the bank account of taxback.com. Endorse the cheque(s), deduct the necessary fee and send me the remaining amount 7. I have not (a) approached or applied to the Revenue Commissioners about these tax affairs or been refused by them for any reason, or, (b) authorised any other party to do so on my behalf. I understand that taxback.com reserve the right to withhold an amount of the refund (their fee) up to the amount as quoted at the time of estimation of the refund in the event that it transpires that the refund amount is lesser than estimated due to the fact that I had previously received a refund for the relevant tax year. 8. I agree to pay taxback.com a filing fee for processing my tax return. Should I avail of any additional services, I understand additional fees may apply. 9. Should I receive the refund directly from any other source other than taxback.com, I agree that I will pay the fee due to taxback.com for the work completed. 10. I understand that the Irish tax authorities will make the final decision on the value of any refund due or any balance due to them by me and that any estimation given by taxback.com, is an estimation, not a guarantee. 11. I agree to and accept the terms and conditions of service as written online at and to any changes in the terms and conditions which taxback.com may effect from time to time, and to the fees of the agent which represents the services I have requested and which are provided by taxback.com and/or its affiliate companies. 12. I understand that information collected in writing and/or verbally for Irish tax return and PRSI filing services can and may be used for internal auditing purposes by taxback.com. I understand that taxback.com, subject to relevant data protection legislation, will cooperate fully with requests from the Revenue Commissioners to provide them with information collected from me either verbally or in written form in connection with my tax return and that the information may be subject to external audit by the Revenue Commissioners. 13. I have provided true, accurate and complete information regarding my income, taxes, assets and personal circumstances to taxback.com and I am duly responsible for any discrepancies in the information provided and my annual tax records with the Revenue Commissioners. 14. I commit to updating taxback.com of any change in my contact or personal details. 15. I understand that taxback.com will submit my application to the relevant tax office as soon as I have been informed of the refund amount and have sent all necessary documentation. Should I wish to cancel my application, I will contact taxback.com immediately. I understand that while taxback.com will make every effort to recall my application, this may not be possible. Taxback.com Commitment 1. We commit to the organisation of the tax return, and any due tax refund and PRSI refund of this customer in line with the full information available to us and the legal regulations of the Republic of Ireland, administered by the Revenue Commissioners of Ireland and the Department of Social and Family Affairs. 2. We commit to transmit any refund due to this customer within three working days, once we have confirmed the payment option and bank details of the client, through a secure method. 3. We commit to providing full information at all times to the customer about his/her tax affairs, through multiple media secure Tax Tracker Account, telephone, and fax. 4. Taxback.com will file tax returns for the tax years requested by the customer. This authorisation to taxback.com means that the Revenue Commissioners of Ireland may communicate/send refunds to taxback.com for tax years other than the tax years requested by the client, so long as the authorisation application is in place. Should this occur, taxback.com will transfer such communication/refunds in its complete form to the customer, unless the customer provides alternative instructions to taxback.com. 5. Taxback.com will retain and protect my personal data as per the relevant data protection legislation. Signed CUSTOMER SIGNATURE Signed SPOUSE SIGNATURE Customer Name Date name Date 6