Surname 

• Telephone number 
• Fax number 
• E-Mail 
• National insurance number 
• Tax reference 

Where sources have ceased, show the date that this occured e.g. the date an account was closed or the date that employment ended. When entering new sources please show the date that this started e.g. the date that an account was opened. The Inspector of Taxes may assume that the income continues unless he is informed of the actual start and end dates.

Employment details

Please enter new sources

Name and address of employer and earnings for this year

Employer 1 

• Amount 
• Employer 2 

Amount 

Amount 

Please enter new sources

Description and amount

• Description 
• Amount 
• Description 
• Amount 
• Description
• Amount 

Please enter details of any new vehicles

• Make/model 
• Engine type/size 
• Date registered 
• Registration 
• List price 
• Purchase Contribution 
• Total value of accessories 
• Business mileage 
• Available for use from 
• Available for use to 
• Private use contributions 
• Fuel provided for private use (Y/N)? YN
• (and employer not fully reimbursed)

Unemployment benefit and supplementary benefit / income support, widowed mothers allowance, invalid care allowance and industrial death benefit. State the name of the unemployment benefit office.Please enter new sources

Description and amount for this year

• Description 
• Amount 
• Description 
• Amount 
• Description 
• Amount 

Give details of self employed or partnership income.

Please enter details of any new Business

Name and address of Business

• Date Trading Commenced 
• Period ended 
• Turnover (if below £15,000) 
• Expenses (if turnover below £15,000) 
• Profit (show loss as negative) 
• Capital Allowances 
• Balancing Charge 
• Enterprise Allowance 

Income and expenses from property that you own in the UK.

Please enter new sources

Please give details of any other property stating address, type of property, income and expenses.

• Description 
• Income 
• Expenses 
• Description 
• Income 
• Expenses 
• Description 
• Income 
• Expenses 

Please enter new sources

• Account description 
• Date Received 
• Amount 
• Account description 
• Date Received 
• Amount 
• Account description 
• Date Received 
• Amount 

Please enter new sources

• Payer 
• Account no.
• Amount 
• Received gross Y/N Y N
• Payer 
• Account no.
• Amount 
• Received gross Y/N Y N
• Payer 
• Account no.
• Amount 
• Received gross Y/N Y N

Dividends received from shares together with name of company and shareholding. Specify type Stock or FID if dividend is not received as cash. Please enter new sources

• Description 
• Holding 
• Date Received 
• Amount 
• Type 
• Description 
• Holding 
• Date Received 
• Amount 
• Type 
• Description 
• Holding 
• Date Received 
• Amount 
• Type 

Dividends received from unit trusts together with name of company and holding. Specify type FID if dividend is not received as cash.

• Description 
• Holding 
• Date Received 
• Amount 
• Type 
• Description 
• Holding 
• Date Received 
• Amount 
• Type 
• Description 
• Holding 
• Date Received 
• Amount 
• Type 

All sources not entered elsewhere including government stocks, bonds, accured income, income from savings and investments abroad company distributions income from trusts, settlements or estates and maintainance and alimony that you receive.Please enter new sources

• Description 
• Date Received 
• Amount 
• Description 
• Date Received 
• Amount 
• Description 
• Date Received 
• Amount 

Mortgages

Please enter new sources

• Description 
• Date paid off 
• Description 
• Date paid off 

Show details of loans on let property or any other qualifing loan.

Please enter new sources

• Description 
• Interest paid this year 

Please enter new sources

• Charity 
• Date deed made 
• Term in years 
• Date of final payment 
• Charity 
• Date deed made 
• Term in years 
• Date of final payment 

Enter details of pension contributions made net of tax where the fund holders claim the tax back directly from the Revenue and add it to your contribution.Please enter new sources

• Pension 
• Contract 
• Amount paid last tax year 
• Amount paid by employer 
• Amount to be paid this tax year 
• Amount to be paid by employer 

Please enter new sources

• Pension 
• Contract 
• Amount paid last tax year 
• Amount to be paid this tax year 

Please enter new sources

• Provider 
• Contract 
• Amount paid last tax year 
• Amount to be paid this tax year 

Enter details of any other outgoing not entered above. For example, expenses in employment, give as you earn, alimony or maintenance paid under the old rules (court orders prior to 15/3/88), rent or interest paid abroad, bonds of annuity, allowance from accrued income purchased and any gift aid contributions.

Please enter new sources

• Description 
• Amount 

If your marital status has recently changed please ammend the details below.

• Marital status 
• Wife's full name 
• Wife's date of birth 
• Date of marriage 

• Name 
• Date of Birth 

Please enter below any other information concerning your income, outgoings or allowances which you feel may be relevant to your Income Tax Return. Please enter 'NONE' if there are no such items.

(Please complete the form and click on the submit button to e-mail the details to ourselves)

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