1N – Claim Form for Repayment of Jamaican Income Tax

OOfficial StampTax Administration JamaicaEast StreetKingstonJamaica, W.I.Claimant’s TRN:1NCLAIM TO REPAYMENT OF JAMAICAN INCOME TAX(Form to be used by Claimant who is Not Resident in Jamaica)YEAR OF CLAIMWhen this form has been completed and signed it should be forwarded to the Commissioner General, Tax Administration Jamaica at theaddress shown above.If, however, repayment of Jamaican tax is claimed under the terms of a Double Taxation Relief Order or Convention between the country ofresidence of the claimant and Jamaica, the form should be signed and forwarded to the Taxation Authorities in the country of residence so thatthe certificate in Section D may be completed.The form will then be sent directly by the certifying Officer to Tax Administration Jamaica.2 0Commissioner General Tax Administration JamaicaName of Claimant:Claimant's Mailing Address:Section A. - FOR COMPLETION BY INDIVIDUALS ONLYNationalityDate of Birth: (yyyy-mm-dd) Marital StatusWife's Christian or other ForenamesRESIDENCE PARTICULARSA married man should complete the column headed "Wife' as if the questions related also to his wifeSelfWife1) In what country do you ordinarily reside? . . . . . . . . . . . . . . . . . . . . .2) Have you ever been resident in Jamaica? If so, state periods of residence. . .3) Have you retained any accommodation for yourself in Jamaica for any period inthe year of claim? If so, state the address & the period for which it was retained.4) Have you visited Jamaica during the year of claim? If so, state the dates ofarrival and departure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section B - FOR COMPLETION BY ALL CLAIMANTS: State briefly the grounds on which repayment of Jamaican tax is claimed :-Section C - DECLARATION. I declare that I /the claimant /am /is /beneficially entitled to the income from the sources specified overleaf and thatto the best of my knowledge and belief all of the particulars given in this form are correctly stated.I authorize repayment to be made to the banker or agent named below:Signature of ClaimantSignature of Authorized AgentSection D - CERTIFICATE OF TAXATION AUTHORITIES OF COUNTRY FOR RESIDENCE.Date.To be completed where relief under a Double Taxation Relief Order or Convention is claimed.I/We certify that is resident in and subject totax in respect of the income*/stated overleaf/*scheduled below.(*Delete as necessary)Schedule :Signature.Official Stampfficial StampDesignation.Date.Form No. 1NPLEASE SEE OVERLEAF FOR CONTINUATION OF FORMTax Administration Jamaica

STATEMENT OF INCOME ACCRUING IN OR DERIVED FROM JAMAICAYEAR ENDED 31ST DECEMBER , 201. Employment or Office - Enter gross earnings.Self($)INCOMEWife($)Jamaican TaxDeducted($)Employers Name. Self . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Wife . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DEDUCTIONS CLAIMED:Self ($) Wife ($)Expenses (attach list of expenses). . . . . . . . . . . . . . . . . . . . . . .Superannuation Contributions.2. Trade, Profession or Vocation - State nature, where and in whatname carried on.the year ended in the year of claim shouldbe stated. Iffor some period other than this you should statethe period covered. A copy of your trading accounts should be attached. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. Pensions & Purchased Annuities.Date Payable By whom payable (state name & address)Amount ($). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. Rents etc.- All rents, premiums and any other from propertyare to be stated. Enclose a list of expenses for each property.Properties. . . . . . . . . . . . . .TotalsGross RentsExpensesNet Rent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. Interest- received by or accrued due to you. Interest includes incomefrom Government Securities, from bonds or debentures whether or notsecured by mortgage or from any other form of indebtedness.Description of loan & from WhomInterest Due DateInterest Rate (%)Gross Interest ($). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .Total6. Royalties:Description of royalties Contract Date Name & Address of payer in Jamaica. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7. Dividends: - Enter the name of the company paying the dividend, thegross dividend and the Jamaican tax deducted. Attach all relevant vouchers.Paying Company:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8. Trust income - or annuities (other tahn purchased annuities), alimony,or other annual sums. Give details and attach all relevant vouchers.9. Profits or Gains - From the provision of industrial or commercialinformation or advice or management or technical services or similarservices or facilities or plant or equipment on hire (other than under ahire-purchase agreement) to any person resident in Jamaica. Givedetails of the nature of services etc..10. Other Income - derived from or accrued in Jamaica not stated above.Total