Application for a
Certicate Of Discharge From Capital Acquisitions Tax
By Virtue Of Section 62(2), Capital Acquisitions Tax Consolidation Act, 2003.
PPSN
D D M M Y Y
RPC012156_EN_WB_L_1
Form C.A.12
Edition 2019
1
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Note: This form should be delivered in duplicate.
Name of Applicant
Applicant’s address
(include Eircode)
The name(s) and address(es) (include Eircode) of the person(s) who is / are shown as the current registered owner(s) of
the property to which this application refers.
(1) (2)
The date as of which such registration was made
Insert here the name and address (include Eircode) of the person to whom the certicate
should be returned
Agent’s Reference
Declaration
I declare that the property described overleaf and in the attached copy Form 5 of the Land Registration Rules, 1972
is not charged under the provisions of the Capital Acquisitions Tax Consolidation Act, 2003, as amended, to gift or
inheritance tax (including probate tax) arising in the period from to
D D M M Y Y D D M M Y Y
Signature of Applicant (or of his agent) Date
D D M M Y Y
Certicate
(For Ofcial Use Only)
(Under Section 62(2) Capital Acquisitions Tax Consolidation Act, 2003)
I certify that, on the facts as disclosed, the property referred to above did not, during the relevant period, become
charged with gift or inheritance tax or that any such charge has been discharged or will be discharged, and the
relevant period is from to
D D M M Y Y D D M M Y Y
Date
D D M M Y Y
for Revenue Commissioners
