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RCT TEMPLATE - Please use shaded areas as a guide for completion of this template. Please ensure all sections are completed accurately. All information contained within this template is
required for your Form 11

Client Name:

Address (include eircode):

PPSN:

Date of Birth:
Civil-
Single Separate Divorce Widowe Co-
Marital Status: Single Married Partners
Parent d d d Habiting
hip
Change in marital/civil status in 2022? Please state date of change & previous status:

Date of Marriage (If applicable):

Occupation:
Occupation spouse (if applicable):

Age(s) of your children (if any):

We also require the following documents as part of our customer due diligence/anti-money laundering procedures (new clients only):

Two forms of current photo ID: passport, drivers licence, national identity card

Proof of address - current copy of one of the following: utility bill, bank or credit card statement, Revenue Commissioners or Department of Social
Protection document showing name and PPSN
Name:
PPS Number:
Description of trade:
Tax Year: 2022
GROSS TRADE INCOME (INVOICED)
GROSS RCT DEDUCTED NET
€ € €
January
February
March
April
May
June
July
August
September
October
November
December
Total Income - - - If any part of your income was subject to professional withholding tax, please return relevant form(s) to us
Do not include income received by the Department of Social Protection eg. PUP etc.
TRADE EXPENSES
€
Materials/Purchases (items for re-sale)
Motor expenses (motor tax, insurance, tolls, repairs & fuel)
Insurance (Public Liability)
Stationery, postage & printing
Advertising
Phone & Internet (include full cost)
Light & Heat (include full cost)
Bank interest on business loan/bank account
Commercial rent of office/work space
Protective clothing
Other - please specify
Other - please specify
Other - please specify
Accountancy Fee (figure will be inputted by Tax Return Plus)
-

Please retain receipts for a period of six years as required by the Revenue Commissioners.
 SCHEDULE OF FIXED ASSETS FOR YOUR BUSINESS (eg. Motor vehicle, machinery, tools, equipment - must be used for the purpose of your trade)

YEAR PURCHASED DESCRIPTION OF ASSET COST

€

10
 TAX YEAR: 2022

SELF SPOUSE
Information required:
(if applicable)

Please note we do not require your PAYE employment details as this information will be available on your Revenue Record.

If YES please tick box Self Spouse

Department of Social Protection (DSP) income? If yes, enter total amount received in 2022 ===>

Type of DSP income as above eg. Jobseekers allowance, jobseekers benefit, carers allowance etc ===>

Please provide statement from Department of Social Protection, this can be requested via www.mygovid.ie or from your local Social Welfare office (Intreo)

Non-PAYE source income in Ireland? eg. Dividends, deposit interest etc. If yes, please attach supporting documentation e.g. Dividend witholding certificate, proof of deposit
interest etc

Foreign income? If yes, please specify ===>

Share Options? If yes, please attach Form RTSO1.

Did you hold proprietary directorship of a Limited Company in Ireland? (own If yes, please provide corporation tax number & % holding.
more than 15%) Please also confirm if you received income from your
directorship in relevant tax year ===>

Gifts or Inheritances? If yes, please specify ====>

Disposal of Assets? eg. Property, shares etc If yes, please specify ====>

If yes, please specify ====>

Did you acquire the following assets in 2022 - shares, residental/commercial

premises, agricultural/development land or any other investment asset?

Additonal fees may apply if you answer 'YES' to any of these questions (unless information was provided at quote stage).
 TAX YEAR: 2022

MED 1 MED 2 QUALIFYING MED 2 CLAIMS:

Include all medical expenses paid by you/spouse (if applicable) Include all medical expenses paid by you/spouse (if applicable)
€ € A. CROWNS
Prescriptions Non-Routine Dental These are restorations fabricated outside the mouth and are permanently cemented to existing tooth tissue.
GP/Consultant Visits Please note a MED 2 form must be signed by your Dentist
Hospital/Ambulance Costs B. VENEERS/ETCHED FILLINGS
Physiotherapy - only on referral from your Doctor These are a type of crown.
Dietary Costs (Celiac/Diabetic)
Medical appliances C. TIP REPLACING
IVF etc This is regarded as a crown where a large part of the tooth needs to be be replaced and the replacement is made
Educational Psychological assessment for a dependent child outside the mouth.
Speech & language therapy for a dependent child
Other - please specify D. POST & CORE BUILD-UPS
These are inserts in the nerve canal of a tooth, to hold a crown.
Subtotal : - Subtotal : -
Less: amount reimbursed by medical insurance etc. Less: amount reimbursed by medical insurance etc. E. INLAYS
An inlay is a smaller version of a crown.
Total Med 1: - Total Med 2: -
F. ROOT CANAL TREATMENT
NURSING HOME EXPENSES This involves the filling of the nerve canal and not the filling of teeth.

Nursing home fees paid G. PERIODONTAL TREATMENT

- The following treatments qualify for tax relief:

Root planing, curettage & debridement, gum flaps, chrome cobalt splints & implants following treatments of gum disease.
Name and address of Nursing Home:
Name & PPS number of patient in Nursing Home: H. ORTHODDONTIC TREATMENT
This involves the provision of braces and similar treatments.
Please retain receipts for a period of six years as required by the Revenue Commissioners.
I. SURGICAL EXTRACTION OF IMPACTED WISDOM TEETH
Relief is allowable when undertaken in a hospital or by a dentist in a dental surgery.

J. BRIDGEWORK
Dental Treatment consisting of an enamel-retained bridge or a tooth-supported bridge is allowable.

Note
Tax legislation specifically excludes relief for expenditure incurred on the extraction, scaling and filling of teeth and the
provision and repairing of artificial teeth or dentures. These items are excluded from relief even if there is an underlying
medical condition that gives rise to the dental treatment or if the treatment in a particular case is considered to be of a
non-routine nature.
 TAX YEAR: 2022
SELF SPOUSE

TAX CREDITS / ALLOWANCES: (if applicable) DOCUMENTATION / INFORMATION REQUIRED:

Please answer below - If Additional Fees
YES please tick box May Occur
Work from home (e-worker) Which was not reimbursed by your employer (PAYE only)? Complete E-worker section - 'additional information' tab

Rent Tax Credit Did you pay rent in 2022?

Medical Insurance Paid by your employer for which you pay BIK (benefit-in-kind)? Attach medical insurance certificate showing premium breakdown of every
person on the policy. ü
Tuition Fees Paid for third level course? Attach receipt of fees paid. Please specify if full-time or part-time course.

Home Carer Do you care for a child for which you receive child benefit, a person over 65 or a person who is permanently State name, date of birth and PPS of person.
incapacitated due to mental or physical disability?

Dependent Relative(s) Financially maintain a relative at your own expense whereby your relative does not earn more than €16,156? State name(s) and relationship to you.

Full Medical Card Hold for any part of the tax year? Copy of your full medical card.

Private Pension Paid via your bank account only? Attach certificate from your provider.
ü
Income Protection (do not include life Paid via your bank account only? Attach certificate from your provider.
assurance or critical illness)

Foreign Earnings Deduction Foreign travel for a minimum of 30 days in a calendar year (PAYE employment only)? Complete Foreign Travel section - 'additional information' tab
ü
Single Parent Primary Carer - (receipt Did you care for your child for more than 6 months and not co-habitate with any partner during the year? State child's name, date of birth, PPS and name/address of school
of child benefit) ü
Single Parent Secondary Carer - (not Did you care for your child for more than 6 months and not co-habitate with any partner during the year? If applicable we will confirm additional information prior to preparation of
in receipt of child benefit) your tax return ü
Incapacitated Child Tax Credit Do you have any children with physical or mental disabilities with reasonable expectation the degree of incapacity State child's name, date of birth, PPS and diagnosis.
prevents your child from maintaining himself or herself over 18 years of age. ü
Maintenance payments Did you make legally enforced mainteance payments to a former partner? Attach legally enforced document.
ü
Guide Dog/Blind person tax credit Do you hold a certificate from an Ophthalmic Surgeon stating that you have impaired vision? Attach certificate from medical consultant.
 TAX YEAR: 2022

Please answer questions below:

SELF SPOUSE

(if applicable)
Country of residence:

Year of arrival to Ireland for work purposes (if applicable):

Country of nationality:

Tax Residence determines what income is chargeable to Irish

Country of domicile: Tax. Please answer all questions.

Country of domicile - country of origin at birth (country of birth of your Father) or country of origin of choice
(country you intend to live in permanently, with no return)

Your domicile affects how foreign-source income is taxed in Ireland. https://www.revenue.ie/en/jobs-and-

pensions/tax-residence/what-is-domicile-and-the-domicile-levy.aspx
E-worker (PAYE employment only): Rent Tax Credit - PLEASE COMPLETE FULLY AS ALL INFORMATION REQUIRED FOR FORM 11
Self Spouse Information required to claim rent tax credit:
Total Days Worked from home Confirm who the rent credit is being claimed for:

Annual Electricity (self, spouse, both, child etc)

Annual Heating
Annual Broadband Are you in receipt of HAP/RAS or any other housing support?

Total Annual Cost € - € - Purpose for which property is being used: