Dividend Withholding Tax Reclaim by fdh56iuoui


									       Dividend Withholding Tax Reclaim

Thank you for choosing to use taxback.com. We look forward to working with you to file your withholding tax
reclaim. In this pack, you will find everything you need to authorise taxback.com to file your reclaim on your
behalf. Please read this pack carefully, sign and return to your local taxback.com office.

1. Client Agreement                                         3. Refund Organiser

This outlines the terms and conditions of the               This section gathers the information we require
agreement between taxback.com and you. Once                 to file your dividend withholding tax reclaim.
you have reviewed this agreement, please sign
and date where marked before returning it to us
and retaining a second copy for your records.

2. Authorisation Forms                                      4. Checklist
This form allows us to deal with both the tax
                                                            We have included a handy checklist so you
office in your home country (to validate your
                                                            can ensure that you have submitted all the
residency) and the tax office in the refund
country (to claim the refund on your behalf).               documentation that is required for your
You will require a copy for each country in                 reclaim.
which you hold dividends and your home tax
office. Please complete and return as many as

Useful taxback.com addresses

AustrAliA                    irelAnd                      united Kingdom                     united stAtes of
Level 2, 600 George Street   12-14 College Green          1st Floor, 277-281 Oxford          AmericA
Sydney NSW 2000              Dublin 2                     Street                             333 N Michigan Ave, Suite
                                                          London W1C 2DL                     2415 Chicago IL 60601

For other taxback.com offices please visit www.taxback.com/contactus.asp

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  Refund Organiser
   First Name:                                                       Surname:

   Date of Birth:                                                    E-mail Address:

   Home Phone Number:                                                Mobile Phone Number:


   Where is your local tax office?        City:                      Country:

   How did you hear about our service?

   Tax number in your home country:

 Investment Income Details
 Please list details relating to the dividend received in the table below. You should note that in many
 countries you can reclaim DWT for up to 4 years after the year in which the dividend was received.
 Please therefore list all your foreign dividends for the last 4 years.

         Company Name                             Country                    Gross Dividend                          Payment Date

   Please make sure you forward the dividend vouchers for each dividend. The relevant tax office will not accept a claim
   without the supporting vouchers.

 During the period in which the dividend income was received:

   Did you buy or sell any of the shares listed above?                                                Yes               No

   Did you have any other income from the countries listed above?                                     Yes               No
   If yes, please provide income source:

   Interest:        Yes              No           Property:    Yes           No

   Other:           Yes              No           If yes, provide information:

   Are you the beneficial owner of the dividend income lists above?                                   Yes               No

Tax Information:

 Please state the country / countries you were tax resident in when the dividend income was paid to you:

* Beneficial ownership broadly means that the income belongs to you and you are not holding the income on behalf of
  someone else.
                                                                                            Visit www.taxback.com for further details about our services
 Authorisation Form

Please note that you should provide as many copies of this form as are required. You need one for each tax country in
which you hold dividends and your home country tax office.

I,                                                                                                           (name, surname)

of,                                                                                                            (insert address)

authorise taxback.com to act as agent on my behalf in dealing with all aspects of filing foreign dividend
withholding tax refund claims.

I confirm that this authorisation will remain in force until finalisation of the respective tax reclaims by the
governing tax authorities.

I authorise taxback.com to contact my local tax office to confirm my tax residency and make any
application(s) to the appropriate foreign tax authorities, as necessary when processing the foreign dividend
withholding tax refunds.

I authorise taxback.com to contact my broker/ custodian bank and or any intermediaries on my behalf to
obtain any tax vouchers or tax certificates as required to process the refunds. I authorise my broker/ custodian
bank or intermediaries to provide these tax vouchers/ certificates to taxback.com as requested.

I authorise the transfer of any refund by bank transfer or cheque to taxback.com.

I understand that taxback.com will retain and protect my data as per the relevant data protection legislation.

I confirm that I have read, understand and have signed the Customer Agreement, which contain the detail of
terms of service provision by taxback.com and the particulars of the authorisation I am providing to taxback.com.



                                                                                 Visit www.taxback.com for further details about our services
Customer Agreement
I confirm that:

1. I understand that taxback.com is a trading name for the services of Taxback Inc., Chicago, USA, and hereby contract with Taxback Inc. to carry out the services
   described herewith.

2. I understand that Taxback Inc will utilise its parent company Taxback Ltd and its subsidiary and affiliate companies to gather information regarding the services
   where necessary and that the contract remains with Taxback Inc for the duration of the service.

3. I authorise Taxback. Inc, and / or its subsidiary undertakings trading as taxback.com and referred to hereafter as the Agent, to prepare this tax reclaim and
   represent me before all appropriate tax authorities as required .

4. I authorise taxback.com, to:

    a. Review my investment income earnings, taxes withheld; allowances due and all other specific areas relating to my
       dividend withholding tax reclaim and to submit my reclaim on my behalf to appropriate tax authorities as required.
    b. Receive all correspondence about my tax affairs and respond as appropriate.
    c. Organise the payment of taxes due to me.
    d. Receive any refunds due from the relevant tax authorities to me by cheque to the taxback.com offices or by bank
       transfer into the bank account of taxback.com, endorse the cheque(s), deduct the necessary fee and send me the
       remaining amount.

5. I confirm that I have not, (a) approached or applied to the relevant tax offices about these tax affairs or been refused by them for any reason, or, (b) authorised any
   other party to do so on my behalf.

6. . I agree to pay taxback.com’s filing fee for processing my tax reclaim. I agree to the contingency fee basis of 10% of the refund amount subject to a minimum fee
    of €75 per reclaim per jurisdiction. Should I avail of any additional services, I understand additional fees may apply.

7. Should I receive the refund directly from any other source other than taxback.com, I agree that I will pay the fee due to taxback.com for
   the work completed.

8. I understand that the relevant tax authorities will make the final decision on the value of any refund due or any balance due to them by me and that any
   estimation given by taxback.com, is an estimation, not a guarantee.

9. I understand that I may have an obligation to declare dividend income received to my local tax authorities and that if I have not done so to date, my local tax
  authorities may revise my tax liability for prior years. I understand that this customer agreement does not allow taxback.com to act on my behalf in this capacity
   and that it is my responsibility to ensure that my tax compliance obligations are satisfied.

10. I agree to and accept the terms and conditions of service as written online at www.taxback.com and to any changes in the terms and conditions which taxback
    may effect from time to time, and to the fees of the agent which represents the services I have requested and which are provided by taxback and/or its affiliate

11. I understand that information collected in writing and/or verbally for tax reclaim services can and may be used for internal auditing purposes by taxback.com. I
    understand that taxback.com, subject to relevant data protection legislation, will cooperate fully with requests from the relevant tax authorities to provide them
    with information collected from me either verbally or in written form in connection with my tax reclaim and that the information may be subject to external audit
    by the relevant tax authorities.

12. I have provided true, accurate and complete information regarding my income, taxes, assets and personal circumstances to taxback.com and I am duly
    responsible for any discrepancies in the information provided with the relevant tax authorities.

13. I commit to updating taxback.com of any change in my contact or personal details.

Taxback.com Commitment
1. We commit to the organisation of the tax reclaim, and any due tax refund of this customer in line with the full information available to us and the legal regulations in
   the relevant jurisdictions.

2. We commit to transmit any refund due to this customer within three working days, once we have confirmed the payment option and bank details of the client,
   through a secure method.

3. We commit to providing full information at all times to the customer about his/her tax reclaim, through multiple media – secure Tax Tracker® Account, telephone,
   email and fax.

4. Taxback.com will only file tax reclaims for the dividends for which information was provided by the client.

5. Taxback.com will retain and protect my personal data as per the relevant data protection legislation.

                     Taxback.com Managing Director

Name in print:         _______________________________________________________________________________________ Signature :         ____________________________

Tax ID Number: ____________________________                                                                            Date:        _________/__________/_________

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                                      Check List


 This checklist will guide you through the taxback.com Dividend Withholding Tax Reclaim Service. Please
 follow the step-by-step guide to ensure that you have submitted all the required documentation.

 1.   Please enclose a signed & dated Client Agreement

 2. Please enclose Authorisation Form

                    One for your home tax office

                    One for each country you are seeking a refund from

 3. Please enclose a completed Refund Organiser

 4. Please enclose the tax voucher for each dividend for which you wish to reclaim withholding tax

                   irelAnd                               united Kingdom
                   12-14 College Green,                  1st Floor, 277-281 Oxford Street
                   Dublin 2                              London W1C 2DL

                                                                         Visit www.taxback.com for further details about our services

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