This certicate should be completed by a person making a payment under deduction of tax. When completed it should be
given to the person receiving the payment for submission to his or her Revenue ofce.
Name of Payer
(Inc Eircode)
Telephone No.
Name of Payee
PPSN (if known)
Telephone No.
Type of Deed or Agreement: (tick 3 as appropriate)
Deed of Covenant Annual Payment* Rent Agreement Other
If you tick ‘Other give details
*e.g. yearly interest such as interest paid under Prompt Payment of Accounts Act 1997, deed of annuity.
Date Deed or Agreement was drawn up D D / M M / Y Y Y Y
GrossAmount TaxDeducted** NetPayment
**Tax should be deducted at the standard rate of income tax. Further information is available on www.revenue.ie.
I certify that the particulars above are true in every respect.
I further certify that I have deducted the amount of income tax shown and that this amount has been or will be accounted for
by me to the Revenue Commissioners.
Signature Date D D / M M / Y Y Y Y
Capacity of signatory (if signing for a company, trust, partnership, etc.)
A claim for tax relief must be made within 4 years after the end of the tax year to which the claim relates.
If your landlord resides outside the state and you pay rent directly to him or her or into his or her bank account either
in the state or abroad, your must deduct tax at the standard rate of tax (currently 20%) from the gross rent payable,
and this form must be completed and given to him or her.
If you are a person with a disability and require this form in an alternative format the Revenue Access Ofcer can be
contacted at accessofcer@revenue.ie
The Revenue Commissioners collect taxes and duties and implement customs controls. Revenue requires customers
to provide certain personal data for these purposes and certain other statutory functions as assigned by the
Oireachtas. Your personal data may be exchanged with other Government Departments and agencies in certain
circumstances where this is provided for by law. Full details of Revenue’s data protection policy setting out how we
will use your personal data as well as information regarding your rights as a data subject are available on our Privacy
page on www.revenue.ie. Details of this policy are also available in hard copy upon request.
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