Form US-Individual 2002
United Kingdom/United States of America Double Taxation Convention (SI 2002 Number 2848)
Application for relief at source from United Kingdom income tax
Claim to repayment of United Kingdom income tax
This form is for use by an individual resident of the United States receiving pensions,
incapacity benefit, purchased annuities, interest or royalties arising in the UK.
Please
give all the information requested in this form and attach supporting documents where necessary use the
US-Individual 2002 Notes at the end of this form to help you, if you need more room, attach a separate sheet,
remember to sign the declaration in Part F, giving details of the capacity in which you sign
see note 5 in the US-Individual 2002 Notes about the certification requirements of the US Internal Revenue Service
If you need help or more information
visit our website: www.gov.uk and look for double taxation in the search facility
or phone us + 44 135 535 9022 if calling from
outside the UK, or 0300 200 3300 if calling from the UK
or write to HM Revenue & Customs, Pay As You Earn and Self Assessment, BX9 1AS
Part A Your personal details
Title (Mr, Mrs, Ms, Miss or other) ____________________
Full name
_______________________________________________
Full residential address
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Enter a phone number where we can contact you. This
may help us deal with your completed form more quickly
.
If you have a tax adviser, please give details.
Advisers name
_______________________________________________
Advisers address
_______________________________________________
_______________________________________________
Phone number __________________________________
Fax number ____________________________________
Reference/contact name (if any)
Please give: Your date of birth
Day Month Year
Your United States Internal Revenue Service
Account Number
Your United States Social Security Number
The location of the Service Center where your latest
tax return was filed and the date on which it was filed.
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.
If you have never lived in the UK, please here
For use by the United States Internal Revenue Service
Please affix your official stamp and attach form 6166. Then send this form to:
HM Revenue & Customs, Pay As You Earn and Self Assessment, BX9 1AS.
You may wish to take a copy of this form for your records.
Please the box Official Stamp
Form 6166 attached.
Day Month Year
Address:
Date tax return filed:
dd mmm yyyy
dd mmm yyyy
Part B Please answer the following questions as appropriate
1. Have you always lived in the United States?
If Yes, go to question 6.
If No, answer question 2 onwards.
Yes No
2. On what date did you begin to live in the United States permanently?
3. From what date have you paid, or will you pay, tax in the United States
on the income that you include in this claim?
(This may differ from the date you have given in answer to question 2)
If you do not have to pay tax in the United States on this income please give the reason(s) on a separate sheet.
4. 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.
If the property is still owned by you but is let to someone else give details, including the
expected annual income.
If the property is no longer available for your use give the reason (for example, sold or
tenancy ended) and give the date on which it was last available for your use.
Yes No
5. How many days did you spend in the UK in this tax year and in the last three tax years?
from 6
th
April to current date ______ days
Tax year to 5 April 20 ____ ______ days
Tax year to 5 April 20 ____ ______ days
Tax year to 5 April 20 ____ ______ days
Now go to question 6.
6. Are you engaged in any trade or business in the United Kingdom?
If Yes, give details on a separate sheet.
Yes No
7. Are you a United States citizen?
If No go to question 8.
If Yes go to question 9.
Yes
No
8. Are you an alien of the United States admitted for permanent residence?
(‘Green card’ holder)
Yes No
9. Do you have a permanent home in the United States?
If No, say on a separate sheet why you think that you qualify for benefits
under the terms of this Double Taxation Convention.
Yes No
Day Month Year
Day Month Year
dd mmm yyyy
dd mmm yyyy
Part B continued as appropriate
10. Are you resident for tax purposes in any country other than the United States?
If Yes, give details on a separate sheet.
Yes No
Answer the following question if you are including in this form interest, royalties or other income as provided for in the
Double Taxation Convention under Articles 11, 12 and 22 respectively. The question does not apply to pensions,
incapacity benefit or purchased annuities.
11. Is any of the income to which this claim refers paid under, or as part of, a
‘conduit arrangement’ as defined in Article 3(1)(n) of this Double Taxation Convention?
See the note about the Part B question in the US-Individual 2002 Notes.
Yes No
Part C Application for relief at source from UK income tax
Complete C.1, C.2, C.3 or C.4 as appropriate, to apply for relief at source from United Kingdom income tax.
C.1 State Pension or Incapacity Benefit
If you receive a UK State Pension or UK Incapacity Benefit, please and enter the date on which payments began.
UK State Pension
date payments began
UK Incapacity Benefit date payments began
C.2 Work pension and/or purchased annuities
Please enter your nationality aside
My nationality is
Enter below full details of your work pension(s) and/or any purchased annuities
If you also wish to apply for an adjustment to be made that takes account of tax already taken off the pension and/or
annuity under the PAYE (Pay As You Earn) system, please see the US-Individual 2002 Notes and this box
It will help us
make the adjustment if you can send a photocopy of the latest P60 that you have received from the payer.
Full description of the income and name and address of the UK payer
Payer’s
reference number
Date(s) on
which payable
C.3 Interest
If you have already received payments of interest with UK income tax taken off, please also complete Part D to
claim repayment of the tax.
If you receive interest from privately arranged loans, see the US-Individual 2002 Notes at C.3 about ‘other interest’
Amount and full title
of security
Name and address in which
security is registered
Registrar’s account number
or reference
Due date(s) of
the interest
C.4 Royalties
Complete columns (a) to (c) below as appropriate, giving the information requested
If you have already received payments of royalties with UK income tax deducted, please also complete Part D to
claim repayment of the tax
For copyright royalties on literary, dramatic,
musical or artistic works
Enter in column (a) a full description of the royalties
Enter in column (b) the date of the contract between you and
the UK payer
Enter in column (c) the payer’s name and address
If payments are made through or by an agent in the UK, also
enter the agent’s name and address
For other royalties
Enter in column (a) a full description of the royalties
Enter in column (b) the date of the licence agreement
between you and the UK payer and attach a copy of the
licence agreement
Enter in column (c) the name and address of the
UK payer of the royalties
Column (a) Column (b) Column (c)
Part D UK income tax taken off payments already received
Give details below if you have received payments with UK tax taken off.
IMPORTANT: If you claim repayment of UK tax taken off any of the following:
a State Pension lump sum
a trivial pension commutation lump sum
income from a trust or estate
please read the US-Individual 2002 Notes about Part D and attach the requested documents.
Source of income
For example “Copyright royalties paid by [name of payer]”
Date of
payment of
income
Amount of income
before UK tax
£
Amount of
UK tax deducted
£
Totals
Part E Authority to make repayment to a nominee
Complete this part if you want us to make the repayment to a nominee. Otherwise the repayment will be made to you at
the address you have shown in Part A of this form.
I authorise the person or organisation named below to receive the amount due on my behalf.
Name of person, bank or building society
Address of person, bank or building society
Postal code
Account number
UK sort code (if appropriate)
Account holders name (This must be the same as the
person entitled to the repayment)
Nominees reference number (if there is one) for you
Signature _____________________________________ (Now also complete and sign the declaration in Part F below)
Part F Declaration
I am beneficially entitled to the income from the source(s) included in this form
The information I have given in this application/claim is correct and complete to the best of my knowledge and belief.
as appropriate
1. I apply for relief at source from UK income tax and undertake to tell HM Revenue & Customs if there is any
change to the information that I have given in this form. (See the US-Individual 2002 Notes about Part C)
2. I claim repayment of
£
Signature ___________________________________________________ Date _________________________
For use by HM Revenue & Customs
Examined ______________________________________ Amount repaid £ _______________________ : ____
Authorised _____________________________________ HMRC date stamp
Crown copyright 2015
click to sign
signature
click to edit
click to sign
signature
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US-Individual 2002 Notes
Use these Notes to help you complete form US-Individual 2002
If after reading these Notes you need further information, please contact HM Revenue & Customs
Our address, website and phone details are in Note 6
1. Double taxation - being liable to pay tax in both countries
If you have income from one country and are resident in another, you may be liable to pay tax in both countries under
their tax laws. To avoid ‘double taxation’ in this situation, the United Kingdom (UK) has negotiated Double Taxation (DT)
treaties with countries that include the United States. The precise conditions that apply to your income from the UK as a
resident of the United States can be found in the text of the UK/USA Double Taxation Convention.
2. Purpose of form US-Individual 2002
Form US-Individual 2002 enables you as a resident of the United States to apply under the UK/USA/Double Taxation
Convention (SI 2002 Number 2848 which, for taxes withheld at source, took effect on I May 2003), for relief at source
from UK income tax on UK-source pensions, (including personal pensions and the State Pension), incapacity benefit,
purchased annuities, royalties and interest. You may use the form to claim relief in respect of any other income
qualifying under Article 22 of the Convention – the ‘Other Income’ article. It also provides for a claim to repayment of
UK income tax in cases where payments of the income have been made with UK tax deducted.
3. Tax vouchers
There is no need to send tax vouchers with your completed form US-Individual 2002, but you should keep them safe in
case they are needed later to support your claim. If you have any doubt about how you have completed the form you can
send vouchers if you think it will help us. If you receive a pension, please see the notes about 3DUWV& and & in the
section ‘Completing the form US-Individual 2002’.
4. Confidentiality
All the information that you provide to HM Revenue & Customs is confidential. We can therefore only discuss your
tax affairs with you or any tax adviser named by you.
5. Residence in the United States and certification requirements
It is a condition of relief from UK income tax under the terms of UK/USA Double Taxation Convention that the beneficial
owner of the income is treated as resident for tax purposes in the United States. Your completed form US-Individual
2002 will therefore need certification by the US Internal Revenue Service (IRS) as evidence that you are considered by
them to be resident in the United States for the purposes of the double taxation treaty. In making this application/claim,
you are consenting to the Internal Revenue Service certifying to HM Revenue & Customs that you are resident in the
United States for the purposes of United States tax.
Where to send the completed form
Send the completed claim form with the US Form 8802, Application for United States Residency Certification, and the
applicable user fee to:
Internal Revenue Service
P.O. Box 71052
Philadelphia, PA 19176-6052
The Application for U.S. Residency Certification and its instructions are available at www.irs.gov
6. Help or further information
If, after using these Notes you need help or more information, please
visit our website: www.gov.uk and look for double taxation in the search facility
or phone HM Revenue & Customs: + 44 135 535 9022 if calling from outside the UK,
or 0300 200 3300 if calling from the UK
or write to HM Revenue & Customs, Pay As You Earn and Self Assessment, BX9 1AS
Please quote your
reference number with us
whenever you contact us.
7. Completing the form US-Individual 2002
Use the following notes to help you complete Parts A to F of form US-Individual 2002.
Please
include on the form only the income on which you are claiming relief from UK tax under the provisions of the
UK/USA Double Taxation Convention
give all the information requested and attach any supporting documents that are asked for, if you need more room,
attach a separate sheet, please write your name and your
HM Revenue & Customs reference number on each
additional sheet
Part A: Personal details of claimant
Please give all the details asked for. If you have a tax adviser, include the tax advisers details.
Part B: Questions
Tick the boxes that apply to you and give any additional information asked for.
Question 12 – ‘Conduit arrangement’
Question 12 on form US-Individual 2002 applies if you include in the form US-Individual 2002 interest, royalties or other
income as provided for in the Double Taxation Convention under Articles 11, 12 and 22 respectively. It asks whether any
income to which the claim refers is paid under a ‘conduit arrangement’.
The definition in Article 3(1)(n) of the Double Taxation Convention is as follows:
“(n) the term “conduit arrangement” means a transaction or series of transactions:
(i) which is structured in such a way that a resident of a Contracting State entitled to the benefits of this Convention
receives an item of income arising in the other Contracting State but that resident pays, directly or indirectly, all or
substantially all of that income (at any time or in any form) to another person who is not a resident of either Contracting
State and who, if it received that item of income direct from the other Contracting State, would not be entitled under a
convention for the avoidance of double taxation between the state in which that other person is resident and the
Contracting State in which the income arises, or otherwise, to benefits with respect to that item of income which are
equivalent to, or more favourable than, those available under this Convention to a resident of a Contracting State; and
(ii) which has as its main purpose, or one of its main purposes, obtaining such increased benefits as are available under
this Convention.”
Note: Please strike through all unused or partially completed sections.
Part C: Application for relief at source from UK income tax
Give the details asked for in Part C to apply for relief at source from UK income tax on future payments of income. Relief
at source may be available in cases where HM Revenue & Customs is able to exercise its discretion to issue a notice
(under Statutory Instrument 1970 Number 488, as amended). We deal with each application on its merits. Where we
cannot agree to allow relief at source or cannot arrange it, you can claim repayment of the UK income tax taken off.
If relief at source is granted, please tell HM Revenue & Customs at the address in Note 6, without delay,
if there is any subsequent change to the information you have given on the form US-Individual 2002.
C.1: UK State Pension
The UK State Pension is a National Insurance benefit and is taxable, but usually paid without deduction of tax. If you
receive a UK State Pension you can claim exemption from UK income tax under the UK/USA Double Taxation
Convention. Tick the ‘UK State Pension’ box in Part C.1 of the form US-Individual 2002 and give the date
payments began.
State Pension Deferral lump sum
If you have received a State Pension Deferral lump sum from which UK tax has been taken off, please complete Part C.1
as above and enter in Part D the amount of the lump sum and the amount of tax taken off. Please send with your form
US-Individual 2002 a photocopy of the notification of the lump sum award that you received from The Pension
Service. This will help us make the repayment.
Incapacity Benefit
Like the State Pension, Incapacity Benefit is taxable but is paid without deduction of tax. If you receive Incapacity Benefit
you can claim exemption from UK income tax under the UK/USA Double Taxation Convention. Tick the
UK Incapacity Benefit box in Part C.1 of
the form US-Individual 2002 and give the date payments began.
C.2: UK pensions and purchased annuities
Certain types of pension and most annuities from the UK, paid to you as a United States resident, can be exempted
from UK income tax.
If the pension and/or annuity is taxed under the PAYE (Pay As You Earn) system, any adjustment will go back to the
latest of the following:
the date on which you became resident in the United States for the purpose of United States tax
the date payments of the income began
the earliest UK tax year which remains in date for claiming repayment of UK income tax
Please send with your form US-Individual 2002
a photocopy of the latest P60 that you have received from the UK payer
of your pension. This will help us make the adjustment.
Government service
If you receive a pension paid by the UK for service to the UK Government or a local authority, there are special
provisions in the UK/USA Double Taxation Convention. Your pension from that employment will be exempt from UK tax
only if you are a United States national as well as being resident there.
If these provisions mean that your pension will be taxed in the UK, you may be able to claim UK allowances, provided
that you satisfy
certain conditions. There is information and a claim form at www.gov.uk (look for double taxation
in the search facility). If you have any questions, please contact HM Revenue & Customs at the address in Note 6.
C.3: UK Interest
UK source interest can be paid to you with no UK tax taken off. Any UK tax that has been taken off can be repaid to you.
Interest from securities
UK tax is deducted from interest on loan stocks issued by
companies which are not quoted on the Stock Exchange and
local authorities
We may be able to arrange for interest on these stocks to be paid with no tax taken off.
Interest from the following UK sources is paid with no UK tax deducted, so there is no need to apply for relief from UK tax
at source.
Please do not enter in 3DUW& of form US-Individual 2002
interest from company loan stocks quoted on the Stock Exchange (paid automatically without deduction of UK tax)
interest from UK government securities (paid automatically without deduction of UK tax)
Additionally, some UK banks and building societies operate a scheme for payment of interest without deduction of UK tax
to non-residents. Ask your UK bank or building society for information. HM Revenue &Customs cannot arrange for
payment of bank or building society interest with no UK tax deducted, so again, please do not enter such interest in
3DUW& of form US-Individual 2002.
Other interest
If you receive interest from privately arranged loans, please give the following details on a separate sheet
Name and address of the UK payer of the interest
Date of the loan agreement
Amount of the loan
Due date(s) of the interest
Please also attach a copy of the loan agreement.
C.4: Royalties
Most UK source royalties can be paid to you with no UK tax taken off. Any UK income tax that has been taken off can be
repaid to you. The Double Taxation Convention allows relief only to the beneficial owner of the royalties. The beneficial
owner is normally the originator of the work or product.
Copyright royalties for literary, dramatic, musical or artistic works
If you are not the originator but have acquired the rights, please attach to the form US-Individual 2002 a copy of the
licence, contract or assignment under which you have acquired the UK rights. This will help us to check that the
beneficial ownership condition in the Double Taxation Convention is satisfied.
Other royalties
Please attach to the form US-Individual 2002 a copy of the licence agreement between you and the UK payer of the
royalties. If you are not the originator of the product giving rise to the royalties but have acquired the rights, please also
attach a copy
of the licence, contract or assignment under which you have acquired the UK rights.
Part D: Claim for repayment of UK income tax
Interest and royalties
As explained in these notes, the UK/USA Double Taxation Convention provides for no UK income tax to be withheld from
payments of interest and royalties. If you have received interest or royalty payments from which UK tax has been taken
off, you may claim repayment of the UK tax. Enter the details asked for in 3DUW'.
Trivial Pension Commutation Payments
Since 6 April 2006, registered pension schemes and life insurance companies can pay ‘Trivial Pension Commutation
Payments’. This means that instead of receiving a small annual pension or annuity, a single lump sum is paid. UK tax is
taken off these amounts under the normal PAYE (Pay as You Earn) rules. If you have received a Trivial Pension
Commutation Payment and on the date the lump sum was paid you were resident for tax purposes in the United States
you can claim repayment of the tax that has been taken off.
Please
enter details of the lump sum in 3DUW' of the form US-Individual 2002
attach Parts 2 and 3 of the form P45 that you received from the payer of the lump sum
For guidance on claiming tax taken off a State Pension Lump Sum, see
the note about State Pension at 3DUW& above.
Income from a trust or estate
If you receive payments from a trust or estate, write the name of the trust or estate in the source of income box
in 3DUW'
If you have received a payment from a discretionary trust, write both the name of the trust and its UK tax reference
number in the source of income box in 3DUW'. HM Revenue & Customs will
look through to the income received by
the trustees and
work out the repayment due to you. It is likely that you will only be entitled to some of the amount
shown as tax credit at the rate applicable to trusts in box 7.2 of the Statement of income from trusts,
R185 (Trust Income), given to you by the trustees
Part E: Payment to a nominee
You should only complete Part E if you want HM Revenue & Customs to make any repayment to a bank, building society,
tax adviser or other person on your behalf. If you want the repayment to be credited to a bank or building society
account, the account holder’s name must be the same as the name of the person entitled to receive the repayment.
We will send the repayment by post so you will need to give the full postal address and other details asked for on the
form. If you want repayment to be made to your tax adviser, please give the reference number (if any) that the tax
adviser uses in correspondence with you.
You must also complete and sign the declaration at Part F if you sign the authorisation in Part E.
Part F: Declaration
You must sign the form US-Individual 2002 personally in Part F. You may claim on behalf of
an unmarried minor (someone under the age of 18)
a mentally incapacitated person
someone who has died
Claims should normally be made by
a parent or guardian on behalf of an unmarried minor
the person authorised by the courts to look after the affairs of a mentally incapacitated adult (or the DWP appointee)
the executor or administrator of the estate of someone who has died (the claim will relate to income up to the date of
death only)
Ask HM Revenue & Customs if you are in any doubt about whether you are the right person to make the claim.
Remember that in these notes and in the form, references to you and your may equally apply to the person on whose
behalf you are claiming.
Privacy and Data Protection
HM Revenue & Customs is a Data Controller under the Data Protection Act. We hold information for the purposes
specified in our notification to the Data Protection Commissioner, and may use this information for any of them. We may
get information about you from others, or we may give information to them. If we do, it will only be as the law permits, to:
• check the accuracy of information
• prevent or detect crime
• protect public funds
We may check information we receive about you with what is already in our records. This can include information
provided by you as well as by others such as other government departments and agencies and overseas tax authorities.
We will not give information about you to anyone outside HM Revenue & Customs unless the law permits us to do so.
These notes are for guidance only and reflect the UK tax position at the time of writing. They do not affect any rights of appeal.
July 2015 Crown copyright 2015
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