This certicate 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 ofce.
Name of Payer
Name of Payee
PPSN (if known)
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
GrossAmount TaxDeducted** NetPayment
€ € €
**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.)