Tax Refund Application Form

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Declaration to the Revenue Commissioners of Ireland (Form PAYE A2)

Mandatory
Section

1. Authorisation to act as agent

I,

(First Name, Surname)

Date of Birth:
Email Address:

PPS Number:

(mandatory)

authorise Red Oak Personal Financial LTD, t/a Red Oak Tax Refunds, TAIN 72344O with an address at Enterprise House, OBrien Road,
Carlow, 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 all documentary evidence of entitlement to credits/reliefs claimed and taxable income sources, will be held for a period
of 6 years beginning at the end of the year of assessment to which the return of income and/or claimed relates by Red Oak Tax
Refunds P or myself
.
I confirm that this authorisation will remain in force until Revenue is formally notified of its cessation by either myself or Red Oak Tax Refunds.

2. Authorisation for Agent to receive refunds on behalf of client

I authorise the transfer of any refund or repayment of PAYE/Income Levy/Universal Social Charge due to me by the Revenue
Commissioners by electronic funds transfer to the following bank account, which is held by Red Oak Tax Refunds
International Bank Account Number (IBAN): IE65AIBK93310422547100
Bank Identifier Code (BIC): AIBKIE2DXXX
Name of Account Holder: Red Oak Tax Refunds
I understand that any refund made by the Revenue Commissioners to my agent Red Oak Tax Refunds, 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 Red Oak Tax Refunds 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
Red Oak Tax Refunds 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 Red Oak Tax Refunds 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 Red Oak Tax Refunds 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

Mandatory

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 Red Oak Tax Refunds to support any refund, credit claims or claims
for allowances and reliefs made to Revenue on my behalf by Red Oak Tax Refunds.
I confirm that I will provide details of all my sources of income to Red Oak Tax Refunds.
I understand that the person selected in Section 1 above is required to retain all documentation relating to any refund or credit
or allowance or relief claimed by the agent on my behalf for a period of 6 years and that Red Oak Tax Refunds will be required to
produce same to Revenue upon request.
Signed: (Client)

Date:

Signed: (Spouse)

Date:

Signed: (Agent)

Red Oak Tax Refunds

Your Personal Details

Internal Use

Mobile Phone:
Postal Address:
Marital Status:

Date Marital Status Changed:

If you are co-habiting and not married, please complete a separate form for each person

Tick years you had a full Medical Card

11

Do you have dependent children?

Yes

13

12
No

14

Medical Card No.

Incapacitated Child Consultation

Required?
How did you hear about us? (if a friend, please provide their name)

Yes

No

Spouse (Husband/Wife) Personal Details (if you are living with a partner, but not married, please completed separate forms)
Spouse Name:
Spouse D.O.B

Spouse Maiden Name:

/

Tick years your Spouse had a

full Medical Card

/
11

Spouse PPS Number:

13

12

Medical Card No.

14

Possible Refunds
Occupation: What was your primary occupation each
year?

2011

2012

2013

2014

N/A

N/A

N/A

2012

2013

2014

Your Spouses Occupation: What was your spouses

primary occupation each year?
Single Parent Tax Status
Tick if you lived with a partner in the year
Tuition Fees (please include receipts)
Tick if you had eligible tuition fees
Service Charges: How much did you spend on Bin
Charges in prior year?

Did either employer pay any part of your or your

spouses Medical Insurance? Tick years.
Other Income: If you or your spouse had income other than
Irish PAYE, Pension or Social Welfare, please describe here

Medical Expenses

2011

Amount spent on allowable Doctor, Hospital,

Prescription or other allowable expenses? Please
include copy of receipts.

Amount of GP prescribed Physiotherapy or similar

treatment expenses?

Did Medical Insurance or other schemes reimburse any

of the medical/dental expenses listed? (enter amount)

Amount of allowable non-routine Dental expenses.

(e.g. Crowns, Root Canal, Braces or other surgical
procedures)

Rent Details Please include details of your rent for each tenancy in the last 4 years.
Were you renting on or before 7/12/2010?
Year 2011
Date commenced:

Yes (complete details below)

Rent Paid to:

/

Landlord
Date ended:

No (skip this section)

Estate Agent
/

Parent
Rent paid in year:

Landlord Overseas

Rental Address:
Landlord/Agent Name & Address:
Year 2012
Date commenced:

Rent Paid to:

/

Landlord
Date ended:

Estate Agent
/

Parent
Rent paid in year:

Landlord Overseas

Rental Address:
Landlord/Agent Name & Address:
Year 2013
Date commenced:

Rent Paid to:

/

Landlord
Date ended:

Estate Agent
/

Parent
Rent paid in year:

Landlord Overseas

Rental Address:
Landlord/Agent Name & Address:
Year 2014
Date commenced:

Rent Paid to:

/

Landlord
Date ended:

Estate Agent
/

Parent
Rent paid in year:

Rental Address:
Landlord/Agent Name & Address:
Please return complete form to Red Oak Tax Refunds, FREEPOST, Enterprise House, OBrien Road, Carlow
or email to refunds@redoaktaxrefunds.ie

Landlord Overseas