MARKET CLAIM REFUND FORM
Please ensure that a refund schedule is attached totalling the amount outlined at (B) below.
Name of Q.I. / Brokerage Firm:
Address of Q.I. / Brokerage Firm:
Irish Tax Reference Number:
Period under review: from: to:
Total amount of DWT refundable to the Q.I. / Brokerage Firm: € (A)
Net amount to be refunded to the Q.I. / Brokerage Firm (after offsets): € (B)
(Note - the amounts at A and B may be the same):
lI declare on behalf of the Q.I. / Brokerage Firm that the amounts stated at A and B are correct.
lI enclose appropriate documentary evidence substantiating these amounts.
lI enclose a copy of the exemption declaration for the underlying beneciary, or where the underlying
beneciary is a client of another Q.I., I hold notications to prove that the underlying client is exempt
from DWT and I undertake to supply Revenue on request, with this documentation and any further
supporting documentation in respect of the entire of this claim or any part thereof.
lI 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 and have returned these to Revenue.
lI have been authorised by the persons listed in the attached schedules to submit Dividend Withholding
Tax reclaims on their behalf.
lI undertake that all monies repaid to us by Revenue on foot of this claim will be paid to the underlying
benecial owners, as appropriate, and we indemnify Revenue against any losses or liability which it may
incur as a result of any failure on our part to comply with this undertaking.
Signed: Relationship to Q.I.
Electronic Funds Transfer (EFT)
Please complete the following:
Name of account holder:
International Bank Account Number:
(Max. 34 characters)
Bank Identier Code:
(BIC) (Max. 11 characters)
Clearing / Routing Code:
MCR1 August 2020
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)