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					Wage tax statement for 2004 and following years
                                 THIS IS A TRANSLATION OF THE DUTCH ‘LOONBELASTINGVERKLARING’.
                                           YOU MUST ALWAYS FILL IN THE ORIGINAL DUTCH FORM!


Inland Revenue                                                                           Income Tax Return
                                                                                         for 2004 and subsequent years
Purpose of this form
1. Recording of personal details
Income tax and National Insurance contributions are normally deducted by                 may be applied by your employer or benefits agency when deducting tax
your employer or benefits agency from your salary or benefit and forwarded to            or premiums, as follows: the general contribution discount, the labour
                                                                                         discount, the old age discount, the supplementary old age discount and
the Inland Revenue. For this reason, your employer or benefits agency has an
                                                                                         the youth disability discount. Together, these contribution discounts are
obligation to keep a record of your personal particulars.
                                                                                         referred to as the income deduction discount. The contribution discounts
2. Do you wish your current employer or benefits agency to apply a discount?             are explained in more detail in the explanatory notes on the other side of
The tariff bands and tax-free allowances are being discontinued with effect from         this form. Only one employer or benefits agency may administer the
2001. These are being replaced with the 'contribution discounts'. A                      income deduction discount at any one time. Use this form to indicate
contribution discount is a discount on the tax or premium payable by you. You            whether or not the employer or benefits agency from which you received
may be entitled to a range of contribution discounts, depending on your                  this form is to apply the income deduction discount. Please read the
personal circumstances. There are five different contribution discounts which            explanatory notes also.




1. Personal details
Are your details included? If so, please check that they are correct, and make whatever changes are necessary.
Surname and initials
Address
Town/City and postal code
Date of Birth                                                                              RSI number (Revenue and Social Insurance number)
Commencement date
Enter the date on which you wish this income tax declaration to take effect. See explanatory note.



2. Do you wish your current employer or benefits agency to apply an income deduction discount?
Please complete the questionnaire below. Or tick the box on the right. If you decide           You do not wish your current employer or benefits agency to
not to do so and proceed to point 3. Please read the explanatory notes also.                   apply the wage deduction discount.

Only one employer or benefits agency may process the income deduction discount at any one time. Read the questions below and indicate whether or not the employer
or benefits agency from which you received this form is to apply the income deduction discount.

Apart from the employer or benefits agency                  Yes Does your current employer or benefits             Yes     Please tick the box
from which you received this form, do you have                  agency process the wage deduction                        You do not wish the employer or benefits
another employer or benefits agency?                            discount                                                 agency from whom you the income
                                                                If in receipt of a national assistance                   deduction discount.received this form to
                                                                benefit, please read the explanatory note.               apply
  No Please tick the box                                    No
  You wish the employer or benefits agency
  from which you received this form to apply
  the wage deduction discount.



3. Signature
Please sign this form and submit it to your employer or benefits agency



Date                                                     Signature




To be completed by your employer or benefits agency
Name of employer or benefits agency


Income tax number                                                                                            Income deduction discount code         0   1




Personnel Department                                                                                                                                        5-3-2002
Wage tax statement for 2002 and following years
Instructions

What should I do with this form?                     discount. In this case you must complete two new        More information
Please complete the form, sign and return to         income tax declaration forms.                           For more information, call the Tax Information
your employer or benefits agency for their                                                                   Service on freephone 0800 - 0543. This Tax
administration.                                                                                              Information Service is available on working days,
                                                     What happens if I do not complete this form?
                                                                                                             Mondays to Thursdays, 8.00 to 22.00 and Fridays
                                                     If you choose not to fill in the income tax
When do I need to complete this form?                                                                        8.00 to 17.00. For specific information concerning
                                                     declaration form, your employer or benefits
You must fill in the income tax declaration                                                                  your own circumstances, please contact the relevant
                                                     agency is obliged to withhold 52% income tax or
form when:                                                                                                   section of the Inland Revenue. The booklets referred
                                                     national insurance premium, which is the highest
- you commence employment                                                                                    to in this information leaflet may be obtained free of
                                                     tax rate. The same applies if you give an incorrect
- when you commence receiving benefit                                                                        charge by contacting the Inland Revenue on
                                                     name and address, or if you do not identify
- when you have more than one employer or                                                                    freephone 0800 - 0043.
                                                     yourself.
  benefits agency and you wish another party
  to apply the wage deduction


What is the income deduction discount?               parent. Those who are in receipt of a Wajong            Preliminary figures
The tariff bands and tax-free sums will be           benefit are entitled to the youth disability            The figures for 2001 had not yet been established
discontinued as of 2001. These are being             discount. The contribution discount amounts are         when drawing up this form. To obtain a copy of the
replaced by the contribution discount. You           listed in the schedule below. Your employer or          most recent figures, call the Tax Information Service
may be entitled to several contribution              benefits agency will be able to tell you which          on freephone 0800 - 0543.
discounts. There are five kinds of                   discounts you are entitled to.
contribution discounts, which may be applied                                                                 Old Age Pension (AOW)
by your employer or benefits agency when             Other contribution discounts                            If you are in receipt of an old age pension (AOW) as
deducting tax or premiums. These are                 There are five other contribution discounts,            a single person or a single parent, you may be
referred to as the 'income deduction                 namely the (supplementary) child discount,              entitled to a supplementary old age discount. In this
discount'. Everyone who is paid a salary or          combined discount and the (supplementary) or            case, ask the agency which pays your old age
who is in receipt of benefit is entitled to the      single parent's discount. To be entitled to these       pension to apply the discount. This is the only body
general contribution discount. Persons               discounts you must have a child dependant in            entitled to process the supplementary old age
receiving a salary are also entitled to a labour     your care. You must apply for these discounts           discount. For more information, please read the
discount. If you are 65 years of age or older,       yourself rather than through your employer or           booklet entitled, 'The New Tax System and the over
you are entitled to old-age discount if your         benefits agency. This you do by sending in either a     65s'.
annual salary or benefit does not exceed             Preliminary contribution discounts refund form
€ 26,321. If you meet these criteria, you are        or an income tax return form. You will find more        Provision for second and third level students
then entitled to a supplementary old-age             information on this in the booklet 'Contribution        There is a special provision for second and third
discount if you are in receipt of an old age         Discounts in the New Tax System'.                       level students. For more information, contact your
pension (AOW) as a single person or a single                                                                 employer

Schedule of contribution discounts
Type of discount (you may be entitled to more than        Amount per year
one discount)                                             Up to 65 years of age                          65 years and older

General contribution discount                             € 1,507                                        € 579
Labour discount                                           € 803 max.                                     € 312?? max.
Old age pension                                           -                                              € 211
Supplementary old age pension                             -                                              € 210
Youth disability discount                                 € 441                                          -
These figures represent the maximum amounts that are applicable only where there is a full tax or premium liability.

Explanatory notes

1 Personal details                                   take into account the particulars entered on this       employer or benefits agency to apply the income
Revenue and social insurance number (RSI)            form. This is usually the due date of the next          deduction discount, and you have also done this
This is the number under which you are               salary or benefit payment.                              already in the case of another employer or benefits
registered with the Inland Revenue. Your                                                                     agency, then you must fill in a new income tax
RSI number may appear on:                            2 Income deduction discount                             return form for the other employer or benefits
- your tax return form and on your income                                                                    agency. If you ask more than one employer or
   tax assessment notices;                           Opting not to fill in the form                          benefits agency to apply the discount, you will
- on your pay slip or else on the annual             If you decide not to fill in the form, e.g. for         receive a discount surplus. You will then have to
   income statement provided to you by your          reasons of privacy, then tick the box. Another          repay this surplus at a later stage.
   employer or benefits agency;                      reason may be that your income is exempt from
- letters from the Inland Revenue regarding          tax and that you wish to avoid a higher tax             Social welfare benefit
   the revenue and social insurance number;          assessment. If you tick the box, your employer or       If you are in receipt of a social welfare benefit
- on your driver's licence or passport.              benefits agency will not apply the income               payment in addition to the payment received from
If you are unable to find your revenue and           deduction discount. You can then apply your             your employer or benefits agency, this welfare
social insurance number, call into the Inland        deduction discount at the end of the tax year on        payment will not qualify for an income deduction
Revenue office dealing with your district. You       your income tax return.                                 discount. However, if your income deduction
will need to produce a valid means of                                                                        discount entitlements are not fully utilised with your
identification (not a driver's licence).             Income deduction discount applied by other              employer or benefits agency, the Social Welfare will
                                                     employer or benefits agency                             take this into account and apply the balance. In this
Commencement date                                    Only one employer or benefits agency may apply          case too, you may assume for the purposes of this
You must fill in the date here from which            the income deduction discount at any one time. If       form that no income deduction discount will apply
you wish your employer or benefits agency to         you indicate on this form that you wish your            to the social welfare benefit payment



Personnel Department                                                                                                                                      5-3-2002

				
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