2022120S Income Tax Return and Self-Assessment for the year 2022

Form 11S
(relating to taxes on income and capital gains for self-assessed individuals)
TAIN GCD
Personal Public Service Number (PPSN)

Remember to quote your PPSN in any

communication with your Revenue office
If submitting this return use any envelope and
write “Freepost” above the Return Address
NO STAMP REQUIRED
Return Address

If you are a mandatory e-Filer you are required to file this return
electronically through Revenue’s Online Service (ROS) in Office of the Revenue Commissioners
accordance with Section 917EA Taxes Consolidation Act 1997 Collector-General's Division
PO Box 354
ROS is the quickest, most effective and secure way to file your
return and pay your tax. It also provides an instant calculation of Limerick
your Income Tax liability. Access ROS at [Link]

RETURN OF INCOME, CHARGES AND CAPITAL GAINS FOR THE YEAR ENDED 31 DECEMBER 2022
CLAIM FOR TAX CREDITS, ALLOWANCES AND RELIEFS FOR THE YEAR ENDED 31 DECEMBER 2022
SELF-ASSESSMENT FOR THE YEAR ENDED 31 DECEMBER 2022
NOTE:
1. A ‘chargeable person’ for self-assessment purposes is a person who is chargeable to tax on that person’s own account or on another
person’s account in respect of a chargeable period. A ‘chargeable person’ is required to complete a Form 11 or a Form 11S Tax Return
and Self-Assessment for the year 2022.
2. An individual with a PAYE source of income and with total gross income from all non-PAYE sources (including income subject to DIRT), of
€30,000 or more is regarded as a ‘chargeable person’ for Self-Assessment and must file a Form 11 or a Form 11S for that year.
3. An individual with a PAYE source of income and with net assessable non-PAYE income (including income subject to DIRT), of €5,000 or
more is regarded as a ‘chargeable person’ for Self-Assessment and must file a Form 11 or a Form 11S for that year.
4. An individual who was granted share options or opened a foreign bank account in 2022 is a chargeable person.
5. A proprietary director is a chargeable person.
6. The Capital Gains Tax Self-Assessment system applies to all individuals, including directors.
Civil Penalties / Criminal Prosecution - Tax law provides for both civil penalties and criminal sanctions for the failure to make a return, the
making of a false return, facilitating the making of a false return, or claiming tax credits, allowances or reliefs which are not due. In the event of
a criminal prosecution, a person convicted on indictment of an offence may be liable to a fine not exceeding €126,970 and / or to a fine of up
to double the difference between the declared tax due and the tax ultimately found to be due and / or to imprisonment.
If there are any changes under the following headings, not already notified to Revenue, enter the new details below
Nature of Primary Trade, Business or Activity
Business Address Main Residence Address

Eircode Eircode

Telephone Telephone
YOU MUST SIGN THIS DECLARATION
I DECLARE that, to the best of my knowledge and belief, this form contains a correct return in accordance with the provisions of the
Taxes Consolidation Act 1997 of
– All the sources of my income and the amount of income derived from each source in the year 2022, and
– All disposals and acquisitions of chargeable assets and the amount of chargeable gains that accrued to me in the year 2022
I DECLARE that, to the best of my knowledge and belief, all the particulars given as regards gifts and inheritances received, tax
credits, allowances and reliefs claimed and as regards outgoings and charges are correctly stated
Signature Date DD /MM / Y Y YY

Capacity of Signatory
Contact Details (in case of query about this return)
Agent's TAIN Contact Name

Client's Reference Telephone or E-mail

RPC016333_EN_WB_L_2_+
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PPSN
If you complete and submit this tax return on or before 31 August 2023 Revenue will calculate the self-assessment for you. This
will assist you in paying the correct amount by the due date. If you submit the return after the 31 August 2023 you must make
your own self-assessment and calculate your own tax, PRSI and USC due. The due date for submission of this return to the above
address is 31 October 2023. On that date you must also pay any balance of tax due for 2022. Where this return is submitted after
the due date, a surcharge (5% where the return is submitted within two months, otherwise 10%) will be added to your tax liability.
Failure to submit your Local Property Tax return will result in a tax surcharge - please see note in the Form 11S Helpsheet
A 'Guide to Completing 2022 Pay & File Self-Assessment Returns' is available from Revenue’s website [Link],
or from Revenue’s Forms & Leaflets Service at +353 1 738 3675.
This return is only to be used for the 2022 tax year.
Legislative references relate to Sections of the Taxes Consolidation Act (TCA) 1997, unless otherwise stated.
The Revenue Commissioners collect taxes and duties and implement customs controls. Revenue requires customers to
provide certain personal data for these purposes and certain other statutory functions as assigned by the Oireachtas. Your
personal data may be exchanged with other Government Departments and agencies in certain circumstances where this is
provided for by law. Full details of Revenue’s data protection policy setting out how we will use your personal data as well
as information regarding your rights as a data subject are available on our Privacy page on [Link]. Details of this
policy are also available in hard copy upon request.
A PERSONAL DETAILS
2 State your civil status, i.e. single, married, in a civil
partnership, widowed, surviving civil partner, married but
living apart, in a civil partnership but living apart, divorced,
a former civil partner
3 If your personal circumstances changed in 2022 enter date of change DD /MM / Y Y YY
AND
State previous civil status (i.e. single, married, etc.)

4 If married or in a civil partnership, insert T in the box to indicate basis of assessment applicable for 2022
Joint assessment Separate assessment Single treatment

5 Spouse’s or Civil Partner's Details

(a) PPSN (d) Date of Birth DD /MM / Y Y YY

(b) Surname
(e) Gender Male Female

(c) First name(s)

(f) Date of Marraige or
Civil Partnership
DD /MM / Y Y YY

6 State the number of Dependent Children

7 If you wish to claim Widowed Person or Surviving Civil Partner with Dependent Child DD /MM / Y Y YY
Tax Credit state date of death of your spouse or civil partner
8 Your Date of Birth DD /MM / Y Y YY

Insert T in the box(es) to indicate for 2022 if Spouse or

you and/ or your spouse or civil partner were Self Civil Partner
10 Permanently Incapacitated

12 A holder of a ‘full’ Medical Card or having entitlement

to one under EU Regulations
13 Entitled to an exemption from PRSI

(a) State reason - Self

(b) State reason - Spouse or Civil Partner

Mandatory Disclosure
19 The number assigned to a transaction by the
Revenue Commissioners under S. 817HB
20 Reportable cross-border arrangement
reference number
Expression of Doubt: If you have a genuine doubt about the correct application of tax law to any item in the
return, provide details of the point at issue in the entry fields provided on page 10
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PPSN
B SELF-EMPLOYED INCOME Primary Trade Trade 2
101 State whether trade refers to self
or spouse or civil partner

102 Description of Trade

(you must clearly describe the trade)

127 Gross Income (Sales / Receipts) . 00 . 00

, , , ,
139 Total Expenses . 00 . 00
, , , ,
108 Net Profit (if a loss show 0.00) . 00 . 00
, , , ,
Start Your Own Business relief
109 If you are claiming relief under S. 472AA for starting your own business
(a) State the date of the commencement of the new business DD /MM / Y Y YY DD /MM / Y Y YY
(b) Insert T in the box to confirm that you have been unemployed for 12 months
immediately before the commencement date (see Form 11S Helpsheet for
more information)
113 Total Capital Allowances . 00 . 00
, , , ,
116 (d) Current year loss for offset against
. 00 . 00
other income - claim under S. 381 / 392 , , , ,
117 (a) Loss Forward from a prior year - S. 382 . 00 . 00
, , , ,
Farmers
119 (a) Relief for qualifying farmer under S. 667B used in 2022 . 00 . 00
, , , ,
(b) Relief for qualifying farmer under S. 667B used . 00 . 00
in prior years , , , ,
(c) Insert T in the box if you are a partner in a Registered
Farm Partnership as defined by S. 667C
(d) Relief for partner in Registered Farm Partnership . 00 . 00
under S. 667C used in 2022 , , , ,
(e) Relief for partner in Registered Farm Partnership . 00 . 00
under S. 667C used in 2021 , , , ,
(f) Relief for partner in Registered Farm Partnership . 00 . 00
under S. 667C used in 2020 , , , ,
(g) Insert T in the box if this trade relates wholly or in part to Share Farming
(h) Insert T in the box if you wish to elect for income averaging
for the year 2022 (and subsequent years)
(i) Insert T in the box if the assessable profits for this year
are computed in accordance with S. 657 (income averaging)
(j) Insert T in the box if you wish to withdraw from income averaging
for the year 2022
(k) (i) Insert T in the box if you wish to temporarily elect out of
income averaging for this year in accordance with S. 657(6A)
(ii) Enter the amount of adjusted net profit which would be assessable for this
year if you had not applied for income averaging . 00 . 00
, , , ,
121 Professional Services Withholding Tax (PSWT)
. .
withheld in the year (before any interim refund) , , , ,
Do not include credit for Relevant Contracts Tax withheld
C IRISH RENTAL INCOME Spouse or
Self
Residential Property Civil Partner
204 Gross Rent Receivable . 00 . 00
, , , ,
205 Expenses . 00 . 00
, , , ,
206 Net Rental income after expenses (if a loss show 0.00) . 00 . 00
, , , ,
Commercial property, land and all other sources of Irish rental income
209 Gross Rent Receivable . 00 . 00
, , , ,
210 Expenses . 00 . 00
, , , ,
211 Net Rental income after expenses (if a loss show 0.00) . 00 . 00
Capital Allowances
, , , ,
213 (c) Wear and tear on fixtures and fittings . 00 . 00
, , , ,
215 Unused losses from a prior year . 00 . 00
, , , ,
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PPSN

D PAYE / BIK / PENSIONS (1) Employment / Pension 1 Employment / Pension 2

Employment / Pension, etc. subject to PAYE Spouse or Spouse or

Self Civil Partner Self Civil Partner
Details entered at Lines 218 to 220 are relevant to Lines 221 to 227
217 Insert T in the box to indicate to whom the income refers
218 Employer’s / Pension Provider's PAYE registered number

219 Employer’s / Pension Provider's name

220 Gross amount of taxable income for this employment /
. 00 . 00
pension (available from your final payslip for 2022) , , , ,
221 Source of income (insert T in the relevant boxes)
(a) Employment
(g) Income in lieu of Social Welfare Payments
(h) Pension - Early Farm Retirement
(i) Pension - Employment pension
(j) Pension - RAC or PRSA

222 (a) Net tax deducted / refunded in this employment

, , . , , .
(b) Insert T in the box if the tax figure above was a refund
223 Gross income for Universal Social Charge (USC) from this
. 00 . 00
employment (available from your final payslip for 2022) , , , ,
224 (a) Net USC deducted / refunded in this employment
, , . , , .
(b) Insert T in the box if the USC figure above was a refund
226 Payment frequency Weekly
Fortnightly
Four weekly
Monthly
Other
227. Is relief due under S. 480B (“week 53”) Yes No Yes No
E PAYE / BIK / PENSIONS (2) Spouse or
PAYE / USC refunded during the year Self Civil Partner
231 PAYE Tax refunded by Revenue for the
Income Tax year 2022 , , . , , .
232 PAYE Tax underpaid (amount collected by
Revenue by reducing your tax credits for 2022) , , . , , .
233 Amount of USC refunded by Revenue for the year 2022 . 00 . 00
, , , ,
238 (b) Allowable Expenses incurred in Employment
(i) Flat Rate Expenses . 00 . 00
, , , ,
(ii) Expenses, other than Flat Rate Expenses, paid by
the claimant wholly, exclusively and necessarily in the . 00 . 00
performance of the duties of the employment or office , , , ,
(Not including expenses claimed through real time at
238(b)(iv) below)

(iii) Remote Working (eWorking) expenses . 00 . 00

, , , ,

(iv) Remote Working Relief already claimed through Real . 00 . 00

Time Credits in 2022 , , , ,

241 Carer’s Allowance paid by Department of Social Protection . 00 . 00

, , , ,
243 Other taxable Social Welfare Payments, Benefits or
. 00 . 00
Pensions (State Pension, Illness Benefit, Occupational , , , ,
Injury Benefit, Jobseeker’s Benefit, Pre-Retirement Allowance, Maternity Benefit, Paternity Benefit,
Parent's Benefit, Adoptive Benefit, Health & Safety Benefit, Pandemic Unemployment Payment (PUP))
(See Form 11S Helpsheet for more information)

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PPSN Spouse or
Self Civil Partner
F FOREIGN INCOME (enter amounts in €)
302 Foreign Pensions
(a) Amount of State Welfare Pension(s) . 00 . 00
, , , ,
(b) Amount of all Other Pensions . 00 . 00
, , , ,
G IRISH OTHER INCOME
402 Irish Income where tax not deducted at source . 00 . 00
, , , ,
403 (a) Irish deposit interest where DIRT deducted . 00 . 00
, , , ,
408 Irish income which suffered tax at the
. 00 . 00
standard rate, other than Line 403(a) above , , , ,
412 (a) Gross amount of income from sources
. 00 . 00
not shown elsewhere , , , ,
(b) Amount of tax deducted . .
, , , ,
(c) Details of income source(s) at Line 412(a)

H EXEMPT INCOME
415 (a) Income received under Rent-a-Room Relief Scheme . 00 . 00
, , , ,
416 Gross income from exempt Childcare Services . 00 . 00
, , , ,
I CHARGES AND DEDUCTIONS
503 Maintenance payments where tax was not deducted
. 00 . 00
(exclude any amounts in respect of children) , , , ,
J PERSONAL TAX CREDITS
515 (a) Home Carer Tax Credit - Amount due for 2022 . 00
,
516 Employee Tax Credit - Insert T in the box if claimed
517 Earned Income Tax Credit - Insert T in the the box if claimed
518 (a) Blind Person’s Tax Credit - Insert T in the box if due
(b) Guide Dog - Number of Guide Dogs maintained by you

519 Assistance Dog - Number of Assistance Dogs maintained by you

520 (a) Dependent Relative Tax Credit - Amount claimed

, . 00 , . 00
(b) Number of Dependent Relatives
526 Tuition Fees
(a) State the name of the student

(b) Amount paid per approved course (do not include

. 00 . 00
administration, exam, registration, capitation fees, etc.) , ,
(c) Insert T in the box if a part-time course
(d) Insert T in the box if fees relate to a training course
527 Single Person Child Carer Credit
If you are the primary claimant, complete section (a). If you are the primary claimant but relinquishing the credit to a
secondary claimant, complete sections (a) & (b). If you are a secondary claimant, complete sections (a) & (c)
If you wish to claim Single Person Child Carer Credit provide the following information in respect of each child
This section must be completed in respect of each child even if you are relinquishing your claim in favour of another individual
Child 1 Child 2
(a) State the nature of your relationship to the child(ren),
i.e. Father, Mother, Grandparent, Legal Guardian, etc.

(i) Child's First Name

(ii) Child's Surname

(iii) Child's Date of Birth DD /MM / Y Y YY DD /MM / Y Y YY

(iv) Child's PPSN
(v) If the child is over 18 years old state name of place of full time instruction, or if the child is incapacitated state nature of incapacity
Child 1 Child 2

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PPSN
(vi) In the year ended 31 December 2022 did the child(ren) named above reside with you Yes No
for the whole or greater part of the year, i.e. in excess of six months
(Note: in the case of a child born during the year the length of time will be reduced on a pro-rata basis)
(vii) In the year ended 31 December 2022 were you living with another person as a couple Yes No
whether married, in a civil partnership, or cohabiting
(viii) Is this claim made in respect of a non-resident child who is a child of a single person
Yes No
who lives outside the State but works in the State (e.g. cross-border worker)
(b) Relinquishing a Claim to Single Person Child Carer Credit
To be completed if you are an individual (the primary claimant) who is relinquishing the Single Person Child Carer Credit in favour
of another individual. State
(i) Name and address of the individual to whom you are
relinquishing this tax credit, include Eircode (if known)

(ii) His or her PPSN (if known) (iii) His or her Date of Birth (if known) D D / M M / Y Y Y Y
(c) Claim for Single Person Child Carer Credit - Secondary Claimant
To be completed if you are an individual (the secondary claimant) who is claiming the Single Person Child Carer Credit as a result
of the primary claimant relinquishing his or her entitlement to the tax credit
(i) In the year ended 31 December 2022 did the child(ren) named above reside with you Yes No
for not less than 100 days
(Note: in the case of a child born during the year of the claim, the number of qualifying days
(in respect of the secondary claimant) will not be reduced on a pro-rata basis)
(ii) In the year ended 31 December 2022 were you living with another person as a couple
whether married, in a civil partnership, or cohabiting Yes No
(iii) Is this claim made in respect of a non-resident child who is a child of a single person
Yes No
who lives outside the State but works in the State (e.g. cross-border worker)
(iv) State the name and address of the individual who
has relinquished his or her entitlement to the tax
credit in your favour, include Eircode (if known)

(v) His or her PPSN (if known) (vi) His or her Date of Birth (if known) D D / M M / Y Y Y Y
(Note: It is not possible to relinquish a credit in respect of one child that resides with you while retaining a credit for another child)
528 (a) Incapacitated Child Tax Credit - State number of incapacitated children
(Note: to qualify for this credit you should submit a completed form ICC1 together with a form ICC2 certified by a medical practitioner)
531 Home Renovation Incentive (HRI) Tax credit due for 2022
. 00 . 00
based on your HRI online claim , ,
535. Rent Tax Credit
Note: Rent tax credit is not due where you are in receipt of Housing Assistance Payment (HAP) / Rental Accommodation Scheme
(RAS) or any other State Housing Support Schemes in respect of the tenancy or where your landlord is a Government Minister or a
Commissioner of Public Works who owns the property in an official capacity, or where your landlord is a Housing Authority or Housing
Association. See [Link] for further information. Self Spouse or
Civil Partner
(a) I confirm that, in respect of this tenancy(ies), I am not in receipt of any rent support
payment from a government scheme / body or agency
(for example HAP / RAS). Insert T in the box(es)
(b) I confirm that the landlord is not a Government Minister or a Commissioner of Public
Works who owns the property in an official capacity, and is not a Housing Authority, or
Housing Association. Insert T in the box(es)
(c) I confirm that I paid rent under a tenancy(ies) in the tax year 2022
Insert T in the box(es)
Please select (d) and / or (e) as appropriate in order to apply for this credit. If neither of the options below applies this
disqualifies you from claiming the Rent Tax Credit. Insert T in the box(es)
(d) I confirm that the rented property is my or my spouse’s / civil partner’s principal private
residence (PPR) in the year 2022, or the rented property is not my PPR but I use it for work
or study, and
• I am not related to my landlord as parent / child or child / parent, or
• I am related to my landlord other than as parent / child or child / parent, (for example,
siblings, grandparent / grandchild, aunt / uncle, niece / nephew, etc) and the property is
registered with the Residential Tenancies Board (RTB) and is not a licence agreement
such as the Rent-a-Room scheme
(e) I confirm that the rented property is used by my child for work or study purposes in the year
2022 and he or she was aged under 23 years prior to commencing third level education;
is not related to the landlord and the property is registered with the Residential Tenancies
Board (RTB) and is not a Rent-a-Room scheme

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PPSN
Where the property is rented for Self Where the property is rented for a
or Spouse or Civil Partner child in third level education
(f) Residential Tenancies Board (RTB)
registration number (if known)
(g) Address of the rented property (include
Eircode) (This property must be located
within the State)

(h) Name of tenant

(i) PPSN of tenant

(j) Start date of tenancy DD /MM / Y Y YY DD /MM / Y Y YY

(k) If the tenancy ended in 2022, provide the end date DD /MM / Y Y YY DD /MM / Y Y YY

(l) Local Property Tax (LPT) Property ID (if known)

(m) Gross amount of rent paid in 2022 . 00 . 00

, ,
(n) Address of Landlord / Agency, if known
(include Eircode)

(o) Insert T in the box if your landlord is non-resident

(p) If the rent was paid to an agent, please
provide the landlord’s name and
address (if known)

(q) Landlord’s PPSN (if known)

Health Expenses incurred by you (and your spouse or civil partner if you are taxed under Joint Assessment)
538 (a) Nursing Home expenses incurred in 2022 . 00
,
(b) PPSN of nursing home resident
(c) Name and address of Nursing Home,
include Eircode (if known)

542 Total Deductions, (Nursing Home only) i.e. sums

. 00
received from local authority, medical insurance, etc. ,
543 Net amount of Nursing Home expenses on
. 00
which tax relief is claimed ,
544 Non-Routine Dental Expenses incurred in 2022 (per Med 2) . 00
,
545 Real Time Health Expenses already claimed through Real Time . 00
Credits in 2022 ,
546 'Other' Health Expenses incurred in 2022 . 00
,
550 Total Deductions (Non-Routine Dental Expenses and 'Other'
. 00
Health Expenses only), i.e. sums received from local authority, ,
medical insurance, etc.
551 Net amount of Non-Routine Dental Expenses and 'Other'
. 00
Health Expenses on which tax relief is claimed , Spouse or
Additional tax credit or relief claimed not shown elsewhere Self Civil Partner
State amount . .
, , , ,
Enter details

L CAPITAL GAINS - Capital Gains for the year 1 January 2022 - 31 December 2022
801 Description of Assets

801 (I) Total Consideration . 00

, ,
805 (f) Claims to Relief - Self (specify relief)

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PPSN
Enter amount of consideration . 00
, ,
806 (f) Claims to Relief -
Spouse or Civil Partner (specify relief)
Enter amount of consideration . 00
, ,
Spouse or
816 Net Chargeable Gain Self Civil Partner
After Personal Exemption (max €1,270 per spouse or
civil partner & not transferable) . 00 . 00
, , , ,
(Note: losses, including losses forward, must be used first)
N CAPITAL ACQUISITIONS
Spouse or
825 If you received a gift or an inheritance in 2022, insert T in the box Self Civil Partner
(Note: 1. Where the value of a gift or an inheritance, when added to the value of prior aggregable benefits (if any) received on
or after 5 December 1991 within the same group, exceeds 80% of the relevant threshold, a Capital Acquisitions Tax
return must be made
2. A gift is treated as having been received on the date of the gift. An inheritance is treated as having been received on
the date of death of a person)

P - SELF ASSESSMENT MADE UNDER CHAPTER 4 OF PART 41A

This return must include a Self-Assessment by the chargeable person to whom the return relates. An individual who fails to make a
Self-Assessment may be liable to a penalty of €250

REMEMBER
You do not have to complete the Self-Assessment panel if you submit this return to Revenue
on or before 31 August 2023
936 Self-Assessment – Income Tax
(a) Amount of income or profits arising for this period . 00
, ,
(Note: This is the amount of your total income for this year before taking account of any deductions, reliefs, or allowances.
Total income includes sources of income from employments, pensions, Department of Social Protection payments, rental
and investment income, as well as self employed income. Where you are in receipt of trading or professional income, it is
the adjusted net profit after taking account of business expenses, but before losses forward or capital allowances)
(b) Amount of tax chargeable for this period
(i) Amount of income tax chargeable for this period . 00
, ,
(Note: This is the amount of income tax charged on the above income, after taking account of deductions, reliefs, and
allowances, but before any tax credits such as personal tax credit, medical expenses, tax deducted, etc)
(ii) Amount of USC chargeable for this period - self . 00
, ,
(iii) Amount of USC chargeable for this period - spouse or civil partner . 00
, ,
(Note: This is the amount of USC chargeable on all of your income (including employment and pension income where
USC has been deducted at source))
(iv) Amount of PRSI chargeable for this period - self . 00
, ,
(v) Amount of PRSI chargeable for this period - spouse or civil partner . 00
, ,
(Note: This is the amount of PRSI chargeable on your trading and investment income only. Do not include PRSI due on
your Irish employment income)
(vi) Total amount of tax chargeable for this period . 00
, ,
(Note: This is the sum of income tax, USC, and PRSI chargeable)
(c) (i) Amount of tax payable for this period before refund / offset at (c)(iii) below . 00
, ,
(ii) Amount of tax overpaid for this period before refund / offset at (c)(iii) below . 00
, ,
(Note: This is the amount of tax payable or tax overpaid for the period, which is computed by reducing the amount of tax
chargeable ((b)(vi) above) by the amount of any tax credits due. Credits include obvious items such as the personal tax
credit or employee tax credit, but also less obvious items such as Dividend Withholding Tax (DWT) withheld / deducted,
DIRT withheld at source, PAYE operated on Schedule E income and Professional Services Withholding Tax (PSWT). This
is the amount of PSWT withheld / deducted, before any interim refunds already made by Revenue)
(iii) Amount of refund (or offset) of tax withheld at source . 00
, ,
(Note: The amount of any tax withheld at source, refunded (e.g. interim refund of PSWT) or offset, should be entered here)
(d) Amount of tax payable for this period . 00
, ,
(e) Amount of tax overpaid for this period . 00
, ,
(Note: This is the amount of tax payable or tax overpaid, adjusted for any refund or offset of tax withheld at source already
made by Revenue. Where there is no refund or offset made, the amount will be the same as (c)(i) or (c)(ii) above)
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PPSN

(f) Amount of surcharge due under S. 1084 because of late filing of this return . 00
, ,
(Note: If you are filing this return after the specified return date for the chargeable period, a late filing surcharge is due
If your return is late the surcharge, which is added on to your tax due, is
• 5% of the tax due or €12,695, whichever is the lesser, where the return is submitted within two months
of the due date
• 10% of the tax due or €63,485, whichever is the lesser, where the return is more than two months late)

(g) Amount of surcharge due under S. 1084 because of non-compliance with . 00

Local Property Tax (LPT) requirements , ,
(Note: Failure to meet your LPT obligations to file and pay will result in a surcharge. Therefore the amount payable in your
Self-Assessment should be increased by 10% subject to a maximum increased amount of €63,485. Where the LPT is
subsequently brought up to date, the amount of the surcharge will be capped at the amount of the LPT liability payable)

(h) (i) Amount of tax paid directly to the Collector-General for this period . 00
, ,
(Note: this is the amount of tax already paid to the Collector-General, i.e. your 2022 Preliminary Tax paid. Do not include
any balancing payments which are now due and will be paid at the time this return is being submitted)

(ii) amount of tax deferred under S. 657(6A) . 00

, ,
(i) (i) Balance of tax payable for this period . 00
, ,
(Note: this is tax payable amount at (d) above, plus the amount of any surcharge due at (f) or (g), less the amount of tax
already paid at (h) (i) and the amount of tax deferred at (h) (ii))
(ii) Balance of tax overpaid for this period . 00
, ,
(Note: this is tax overpaid amount at (e) above, less the amount of any surcharge due at (f) or (g), plus the amount of tax
already paid at (h) (i) and the amount of tax deferred at (h) (ii))
I DECLARE the above to be my Self-Assessment to Income Tax for the year 2022

Signature Date DD /MM / Y Y YY

Capacity of Signatory

937 Self-Assessment – Capital Gains Tax

(a) Amount of chargeable gains arising for this period . 00
, ,
(Note: This is the amount of chargeable gains for this period less any reliefs which reduce the chargeable gain)

(b) Amount of tax chargeable for this period . 00

, ,
(Note: This is the amount of tax chargeable on the chargeable gain after taking account of any deductions, reliefs or
allowances, e.g. personal allowance or transfer of business to a company)
(c) Amount of tax payable for this period . 00
, ,
(Note: This is the amount of tax due after any Retirement Relief or Credit for Foreign Tax paid have been deducted
from tax chargeable)
(d) Amount of surcharge due under S. 1084 because of late filing of this return . 00
, ,
(Note: See 936(f))
(e) Amount of surcharge due under S. 1084 because of non-compliance with LPT . 00
requirements , ,
(Note: See 936(g))
(f) Amount of tax paid directly to the Collector-General for this period . 00
, ,
(Note: The amount entered here will be the amount of direct tax paid for the year plus any amounts that may have been
credited to the year from another year or tax type)
(g) (i) Balance of tax payable for this period . 00
, ,
(ii) Balance of tax overpaid for this period . 00
, ,
I DECLARE the above to be my Self-Assessment to Capital Gains Tax for the year 2022

Signature Date DD /MM / Y Y YY

Capacity of Signatory

PAGE 9
2022120S ANY PANEL(S) OR SECTION(S) THAT DO NOT REQUIRE AN ENTRY SHOULD BE LEFT BLANK

PPSN

Bank Details
If you wish to have any refund paid directly to your bank account, please supply your bank account details

Single Euro Payments Area (SEPA)

Account numbers and sort codes have been replaced by International Bank Account Numbers (IBAN) and Bank Identifier Codes
(BIC). These numbers are generally available on your bank account statements. Further information on SEPA can be found on
[Link]
It is not possible to make a refund directly to a foreign bank account that is not a member of SEPA
IBAN (Maximum 34 characters)

BIC (Maximum 11 characters)

If you are married or in a civil partnership and have opted for Joint Assessment in 2022, please provide your spouse’s or
civil partner’s bank account details
IBAN (Maximum 34 characters)

BIC (Maximum 11 characters)

(Note: Any subsequent Revenue refunds will be made to this bank account unless otherwise notified)

Expression of Doubt provided by S. 959P

If you have a genuine doubt about the correct application of tax law to any item in the return, insert T in the box
and provide details of the point at issue in the entry fields below
(This section is only for genuine Expressions of Doubt as provided for by S. 959P. It should not be used for general notes
or comments)
(a) Provide full details of the facts and circumstances of the matter to which the Expression of Doubt relates

(b) Specify the doubt, the basis for the doubt and the tax law giving rise to the doubt

(c) Identify the amount of tax in doubt in respect of the

. 00
chargeable period to which the Expression of Doubt relates , ,
(d) List the supporting documents that are being submitted in relation to the matter involved. These documents should accompany
this return

(e) Identify any published Revenue guidelines that you have consulted concerning the application of the law in similar circumstances

PAGE 10
 PAY AND FILE - 31 OCTOBER 2023
Please read the important information on this page before completing the payslip overleaf

IMPORTANT Methods of Payment

You can make a payment against a tax liability using one of the following:

1. Revenue Online Service (ROS)

ROS customers can make payments online through ROS. To access ROS or to register for ROS, click on the ROS link on the Revenue home
page at [Link].

2. myAccount
myAccount customers can make payments online by clicking on the myAccount link on the Revenue home page. You can register for
myAccount on the “Register for myAccount” link on [Link]. You will need your PPSN and a password to make a payment.
You can make payments online using:
- a debit card or a credit card
- a once off debit - a ‘Single Debit Instruction’ - using a bank account.

3. Direct Debit
For information on how to pay Preliminary Income Tax by monthly Direct Debit, visit the Revenue website at [Link] or phone
the helpline at 01 738 3663. Please note that the Direct Debit facility applies only to Preliminary Tax and all Direct Debit applications should
be made online through ROS using the Direct Debit link on My Services screen.

4. Cheque
- Complete the Statement of Net Liabilities on the payslip to ensure your cheque payment is allocated to the correct tax years.
- Ensure the cheque amount equals the total in the ‘Total Net Amount’ box on the payslip.
- Make your cheque payable to the Collector-General.
- Forward the completed payslip and your cheque to Collector-General, PO Box 354, Limerick.
- Please note that cheque payments can take longer to process and update to your customer record.
- Paying online using ROS or myAccount is the fastest and most secure way to make your payment.

Importance of Prompt Payments

- Ensure that you allow sufficient time - at least three working days - for your payment to reach the Collector-General by the due date.

- Late payment of tax carries an interest charge.

- Failure to pay tax, or to pay it on time, can result in enforced collection through the Sheriff, Court proceedings or a Notice of Attachment.

Enforcement carries costs, additional to any interest charged.

ENQUIRIES
Any enquiry regarding liability should be addressed to your local Revenue Office.
Any enquiry regarding payment should be addressed to the Collector-General, Sarsfield House, Francis Street, Limerick, V94 R972.

SEE PAYSLIP ON REVERSE

RPC017297_EN_WB_L_2_Form 11S
 Name PPSN
PAY AND FILE
31 OCTOBER 2023

IMPORTANT Please read the information below and overleaf before completing the Statement of Net Liabilities

In accordance with the Taxes Consolidation Act 1997, you are obliged to submit the following return and payment on
or before 31 October 2023:

Preliminary Tax for the year of assessment 2023 including Universal Social Charge contributions

Payment of any balance of Income Tax due for the year of assessment 2022

Return of Income and Capital Gains for the year of assessment 2022

How to complete the payslip

Please complete the Statement of Net Liabilities on the payslip below to ensure your Income Tax payment is promptly allocated to the
correct tax years. You must complete the Statement of Net Liabilities whether you are using one of our online payment facilities on ROS or
myAccount or if you are paying by Direct Debit or Cheque. Please see overleaf the payment options that are available to you. Please note
that paying online using ROS or myAccount is the quickest and most secure way to make your Income Tax payment. Once completed,
forward the payslip to the Collector-General, PO Box 354, Limerick.
Please enter an amount in the relevant space on the Statement of Net Liabilities for the following:

RPC017297_EN_WB_L_2_Form 11S
1. Preliminary Tax 2023
The minimum Preliminary Tax payment you are obliged to make is an amount equal to the lesser of 90% of your final Income Tax liability
for 2023 or 100% of your final liability for 2022. If you are paying your 2023 Preliminary Tax by monthly Direct Debit, leave this box blank.

2. Balancing Amount 2022

Insert any outstanding balance of Income Tax for the year of assessment 2022. Tax already paid for this year should be taken into
consideration when calculating the amount of the balance outstanding.
If you have calculated that there is a credit due to you for this year, enter the amount and tick the box (x) to indicate that the value is a credit.
The credit will be automatically offset against any liabilities for other years on the Statement of Net Liabilities.

3. TOTAL NET AMOUNT

The Total Net Amount figure should match the sum total of declarations that you are making for the above periods.
If you have calculated that you have no Preliminary Tax 2023 or Balancing Amount 2022, enter a single ‘0’ in the appropriate box for that
category on the Statement of Net Liabilities.

IMPORTANT NOTE:
If you file this return on time, but at the date of filing, you have failed to submit your Local Property Tax (LPT) return or have failed to either
pay the LPT due or enter into an agreed payment arrangement, a surcharge should be added to the final liability. Therefore, the amount
payable in your Self-Assessment should be increased by 10%. Where the LPT is subsequently brought up to date, the amount of the
surcharge will be capped at the amount of the LPT liability involved. For assistance, you may wish to call the LPT Branch on 01 738 3626
(ROI only) or +353 1 738 3626 (outside ROI).

Form 11S € Payslip

SAMP
€ Statement of Net Liabilities
Whole Euro only - DO NOT ENTER CENT

LE
Income Tax Preliminary Tax 2023
PPSN: 0000000AB
1 5 5 ,
5 5 5 ,
5 5 5 .
00 X
Name: A. N. OTHER Place X in the
box above if
Income Tax
Income Tax Balancing Amount 2022 2022 is a

00
credit
2 2 2 , 2 2 2 ,2 2 2 .
Signature: A.N. OTHER Date: 12-09-2023
If you are paying by cheque, the cheque amount should equal the total in the ‘Total Net Amount’

TOTAL NET AMOUNT P&F

1 + 2 ABOVE 3 3 ,3 3 3 ,3 3 3 .
00 U