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Please complete relevant sections in BLOCK CAPITALS

form 12 AApplication for a Certificate of Tax Credits and Standard Rate Cut-Off PointPlease complete relevant sections inBLOCK Personal DetailsTitleFirst NameSurnameAddressDate of BirthNationalityPPS Number(See Note 3 on help sheet)If you have a PPS provide it, give:Your Birth Surnameif differentYour mother s birth SurnameB. Residence Details(see note 3 on Help Sheet)If you lived outside the State during the last 24 months Please state:Date you went abroadDate of arrival/return(if an Irish National)to the StateCountry of residence prior toIntended duration of your stayarrival here( number of months/years)Are you here on a Permanent or Temporary Basis ( Please tick ):PermanentTemporaryC. Employment/Pension Details( Please get this information from your employer)Name of Employer/Pension PayerTel:Address of Employer/Pension PayerEmployer s PAYE Registered No.

Detach and Keep this Help Sheet Application for Certificate of Tax Credits You will need to complete Form 12A (attached) to apply for your Certificate of Tax

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