NI 79 For NIS Refunds

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THE NATIONAL INSURANCE BOARD N.I.

79

APPLICATION FOR REFUND

NAME OF EMPLOYER: ..................................................................................................................................................


REGISTRATION NUMBER
ADDRESS: ......................................................................................................................................................................

SERVICE CENTRE AT WHICH APPLYING: ..................................................................................................................

POSTAL ADDRESS PERIOD OF AMOUNT OF REASON FOR OVERSTAMPING STILL EMPLOYED


NAME OF INSURED PERSON N.I. NUMBER OF INSURED PERSON OVERSTAMPING REFUND (State whether card attached) WITH YOU

YES NO

.........................................................................................
N.B. IF REASON FOR OVERSTAMPING IS THAT EMPLOYEE IS OVER 65, ENSURE
THAT A COPY OF HIS BIRTH CERTIFICATE IS ATTACHED. SIGNATURE OF EMPLOYER

............................................
NIB/GS:10/87 DATE

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