R40(M) PAGE 1 HMRC 01/15
Claim for repayment of tax deducted
from savings and investments
How to fill in this form
Please fill in this form with details of your income for the
above tax year. The enclosed R40 Notes will help you (but
there is not a note for every box on the form). If you need
more help with anything on this form, please phone us on the
number shown above.
If you are not a UK resident, do not use this form please
contact us.
Please do not send us any personal records, or tax
certificates or vouchers with your form. We will contact
you if we need these.
Please allow 4 weeks before contacting us about your
repayment. We will pay you as quickly as possible.
Use black ink and capital letters
Cross out any mistakes and write the
correct information below
before tax was taken off
Tax taken of f box 2.7
£
2.8
£
24350 51
49
If you would like the payable order to go to your bank,
building society or any other nominee, enter their name,
address and postcode
I
11.1
G I ROBANK
R
Personal details
Date of birth DD MM YYYY
National Insurance number
Name and address – if it is different from above. Please
write the correct details underneath the wrong ones, and
put ‘X’ in the box
Your contact phone number(s)
Your phone number
Your agent’s phone number
If this is an interim claim and you expect to receive more
income before the end (5 April) of the above tax year,
put ‘X’ in the box
1.3
1.2
1.1
Year to:
This form is designed to be read by machine – please follow
the completion instructions so that it may be read correctly
and:
write inside the boxes, using black ink and capital letters
if you make a mistake, cross it out and write the correct
information below it
leave blank any boxes or sections that do not apply to you
please do not strike through them
Your reference
Tax reference
1.4
1.5
If not already shown, please enter your
name and address in this box to make sure
that we can deal with your claim
5 April
dd mmm yyyy
R40(M) PAGE 2
Total pay from all employments, before tax taken off
(from P60/P45)
Tax taken off box 2.1 income
State Pension – enter the amount you were entitled to
receive in the year not the weekly or 4 weekly amount.
Read the notes
If you do not receive State Pension, put ‘X’ in the box
Total of other taxable state benefits
Tax taken off any taxable Incapacity Benefit included
in box 2.5
Total of other pensions and retirement annuities,
before tax taken off
Tax taken off box 2.7
Additional information – read page 3 of the notes
2.9
2.4
2.2
2.1
2.8
2.7
2.6
2.5
2.3
£
£
£
£
£
£
£
UK employment income, pensions and state benefits
Net interest paid by banks, building societies etc and
purchased life annuities after tax taken off
Tax taken off
Gross amount the amount before tax taken off
If you get interest that has not been taxed at all, put the
total in this box, not in box 3.3
UK company dividends (but do not add on the tax credit)
Dividends from UK authorised unit trusts, open-ended
investment companies and investment trusts (but do not
add on the tax credit)
Stock dividends enter the appropriate amount in cash/
cash equivalent of the share capital without any tax
3.7
3.6
3.5
3.4
3.3
3.2
£
£
£
£
£
£
£
3.1
UK interest and dividends
Trust, settlement and estate income
Please give the Unique Taxpayer Reference (UTR)
of the trust
Net amount taxed at trust rate after tax taken off
Tax paid or tax credit on box 4.2 income
Net amount of non-savings income after tax taken off
Tax paid or tax credit on box 4.4 income
Net amount of savings income after tax taken off
Tax paid or tax credit on box 4.6 income
Net amount of dividend income
Tax credit on box 4.8 income
Income payments from settlor-interested trusts
Income taxed at 22% after tax taken off
4.9
4.8
4.7
4.5
4.4
4.3
4.2
4.1 4.6
4.11
4.10
£
£
£
£
£
£
£
£
£
£
With joint accounts, only enter your share of the interest received.
R40(M) PAGE 3
Income
Expenses allowable for tax
Profit
Loss
Land and property losses brought forward from
earlier years
5.5
5.4
5.3
5.2
£
£
£
£
£
5.1
UK land and property
Chargeable event gains
Number of years
Tax treated as paid on box 7.1 income
Other income and benefits (gross amount)
Tax taken off box 7.4
Description of box 7.4 income, etc
7.6
7.5
7.4
7.3
7.2
£
£
£
£
7.1
Gift Aid payments made in the year of claim
Gift Aid payments made in the year of claim but
treated as if made in the preceding year
Total of any 'one-off' payments included in box 8.1
Gift Aid payments made after the end of the year of
claim but to be treated as if made in that year
8.4
8.3
8.2
£
£
£
£
8.1
Any other income and benefits
Gift Aid
Foreign income
Please enter the sterling equivalent of your foreign income and tax paid. If there is more than one country of origin,
please give the additional details on a separate sheet.
Foreign dividends (net amount)
Foreign tax taken off box 6.1 income
Foreign dividends eligible for tax credit (net amount)
Foreign tax taken off box 6.3 income
Foreign property income before expenses
Foreign property expenses allowable for tax
Foreign tax taken off box 6.5 income
Foreign interest and other savings
Foreign tax taken off box 6.8 income
Foreign pensions and any other foreign income
Foreign tax taken off box 6.10 income
Country of origin
6.4
6.3
6.12
6.11
6.10
6.9
6.8
6.7
6.6
6.5
6.2
£
£
£
£
£
£
£
£
£
£
£
6.1
R40(M) PAGE 4
Declaration Please make sure that you have read the R40 Notes at section 12.2 before signing
Blind Person's Allowance
If you are registered blind (severely sight impaired)
with a local authority, or other register, put 'X' in the box
Please also consider box 10.6 below
Enter the name of the local authority, or other register
(or 'Scotland' or 'Northern Ireland', as appropriate)
9.29.1
Please sign and date this form and then write your full name (in capital letters) in the space provided
The information I have given on this form is correct and complete to the best of my knowledge.
Signature Date
Name and title in capital letters
12.1
If you have signed on behalf of someone else, enter the
capacity, for example, parent, executor, receiver, attorney
Tick this box if you do not need a claim form in future
12.2
12.3
If you would like the payable order to go to your
UK bank, building society or any other nominee,
please enter in full the name, address and postcode
If your nominee is your adviser, enter their reference
Branch sort code
Account number
Name of account holder
Bank or building society roll or reference number, if you
have one
11.2
11.5
11.4
11.3
11.1
11.6
Repayment instructions
If the payable order is to be sent to your bank or building
society, fill in boxes 11.1, 11.3, 11.4, 11.5 and 11.6, if applicable
To claim the full allowance, enter your spouse’s or civil
partner’s full name
If, as a couple, you have already asked us to give all of
the minimum amount to your spouse or civil partner,
put ‘X’ in the box
If you’ve already agreed that half of the minimum amount
is to go to your spouse or civil partner, put ‘X’ in the box
Your spouse’s or civil partner’s date of birth if older than
you and you filled in boxes 10.1, 10.2 or 10.3
DD MM YYYY
Enter the date of the marriage or civil partnership
DD MM YYYY
Any unused Married Couple’s, or Blind Person's Allowance
can be transferred from one spouse or civil partner to the
other – if you want us to send you a form to do this,
put ‘X’ in the box or you can download it from
www.hmrc.gov.uk/forms/575-t-man.pdf and attach it to
this claim form.
10.6
10.5
10.4
10.3
10.2
10.1
Married Couple's Allowance
This allowance is only due if you, or your spouse or civil partner, were born before 6 April 1935. Read page 11 of the Notes.
dd mmm yyyy
dd mmm yyyy
click to sign
signature
click to edit
dd mmm yyyy
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