MARKET CLAIM PAYMENT FORM
DIVIDEND WITHHOLDING TAX (DWT)
(as provided for by Chapter 8A of Part 6 of the Taxes Consolidation Act, 1997
as inserted by Section 27(a) of the Finance Act, 1999)
Name of Q.I. / Brokerage Firm
Address of Q.I. / Brokerage Firm
(incl. Eircode)
Irish Tax Reference Number (if relevant)
Period under review to
Total amount of DWT payable by the Q.I. / Brokerage Firm € (A)
Net amount to be paid by the Q.I. / Brokerage Firm (after offsets) € (B)
(note - the amounts at A and B may be the same)
• I declare on behalf of the Q.I. / Brokerage Firm that the amounts stated at A & B are correct
• I further declare that there is documentary evidence to substantiate these amounts and that
this evidence will be made available to the Revenue Commissioners for inspection, when
requested to do so in writing by the Revenue Commissioners
• I declare that the Q.I. / Brokerage Firm has accounted for DWT for which it was required to
account in respect of all previous market claim transactions
PAYMENT ONLY
For ofcial use only
• I enclose the amount outlined at B and
have completed the payslip at the end of this form
Signed (declarant)
Title (Mr. / Ms. etc.) Date
Relationship to the Q.I. / Brokerage Firm
hrpdecpt
PAYMENT REFERENCE No.
€ C
EFT
D D M M Y Y Y YD D M M Y Y Y Y
D D M M Y Y Y Y
NAME OF Q.I. / BROKERAGE FIRM
CORPORATION TAX REGISTRATION No.
(where relevant)
PAYMENT DATE
I DECLARE THAT THE AMOUNT SHOWN BELOW IS THE AMOUNT
I AM LIABLE TO REMIT TO THE COLLECTOR GENERAL
SIGNED
DATE
THIS IS NOT A BANK GIRO
DWT PAYSLIP
D D M M Y Y Y Y
D D M M Y Y Y Y
For: COLLECTOR-GENERAL
DIVIDEND WITHHOLDING TAX SECTION
REVENUE COMMISSIONERS
ST. CONLONS ROAD, NENAGH,
CO. TIPPERARY, E45 T611
RPC013899_EN_WB_L_1
