Claim For Repayment of Tax Deducted From Savings and Investments

Claim for repayment of tax deducted
from savings and investments

If not already shown, please enter your
name and address in this box to make sure
that we can deal with your claim
Year to:
Your reference
Tax reference
5 April
How to fill in this form

Please fill in this form with details of your income for the
above tax year. The enclosed R40 Notes will help you (but
there is not a note for every box on the form). If you need
more help with anything on this form, please phone us on the
number shown above.
If you are not a UK resident, do not use this form please
contact us.
Please do not send us any personal records, or tax
certificates or vouchers with your form. We will contact
you if we need these.
This form is designed to be read by machine please follow

the completion instructions so that it may be read correctly
and:
write inside the boxes, using black ink and capital letters
if you make a mistake, cross it out and write the correct
information below it
leave blank any boxes or sections that do not apply to you
please do not strike through them
Cross out any mistakes and write the
correct information below
Use black ink and capital letters
before tax was taken off
Please allow 4 weeks before contacting us about your

repayment. We will pay you as quickly as possible.
2 4 3 5 0 5 1
49
Tax taken off box 2.7
2.8
R
11.1
If you would like the payable order to go to your bank,

building society or any other nominee, enter their name
address and postcode
G I R OB A N K
Personal details
1.1
Date of birth DD MM YYYY
1.4
Your contact phone number(s)

Your phone number
1.2
National Insurance number

Your agents phone number
1.3
Name and address if it is different from above. Please

write the correct details underneath the wrong ones, and
put X in the box
R40(M)
1.5
PAGE 1
If this is an interim claim and you expect to receive more

income before the end (5 April) of the above tax year,
put X in the box
HMRC 01/15
UK employment income, pensions and state benefits

2.1
Total pay from all employments, before tax taken off

(from P60/P45)
2.5
Tax taken off box 2.1 income
2.3
2.7
Total of other pensions and retirement annuities,

before tax taken off
2.8
2.4
Tax taken off any taxable Incapacity Benefit included

in box 2.5
State Pension enter the amount you were entitled to

receive in the year not the weekly or 4 weekly amount.
Read the notes
2.6
2.2
Total of other taxable state benefits
If you do not receive State Pension, put X in the box
2.9
Additional information read page 3 of the notes
UK interest and dividends

With joint accounts, only enter your share of the interest received.
3.1
Net interest paid by banks, building societies etc and

purchased life annuities after tax taken off
3.5
Tax taken off
Dividends from UK authorised unit trusts, open-ended

investment companies and investment trusts (but do not
add on the tax credit)
3.3
Gross amount the amount before tax taken off
3.4
3.6
3.2
UK company dividends (but do not add on the tax credit)
3.7
If you get interest that has not been taxed at all, put the
total in this box, not in box 3.3
Stock dividends enter the appropriate amount in cash/

cash equivalent of the share capital without any tax
Trust, settlement and estate income

4.1
Please give the Unique Taxpayer Reference (UTR)

of the trust
4.6
4.7
4.2
Net amount taxed at trust rate after tax taken off
Tax credit on box 4.8 income
Tax paid or tax credit on box 4.4 income
Income payments from settlor-interested trusts
4.11
Income taxed at 22% after tax taken off
R40(M)
4.10
4.5
Net amount of dividend income
Net amount of non-savings income after tax taken off
4.9
4.4
4.8
4.3
Net amount of savings income after tax taken off
PAGE 2
UK land and property

5.1
Income
5.2
5.4
Expenses allowable for tax
Loss
5.5
Land and property losses brought forward from

earlier years
5.3
Profit
Foreign income
Please enter the sterling equivalent of your foreign income and tax paid. If there is more than one country of origin,
please give the additional details on a separate sheet.
6.1
Foreign dividends (net amount)
6.2
6.3
6.4
6.5
6.6
6.11
Foreign tax taken off box 6.10 income
6.12
Foreign pensions and any other foreign income
Foreign property expenses allowable for tax
6.10
Foreign property income before expenses
6.9
Foreign interest and other savings
6.8
Foreign dividends eligible for tax credit (net amount)
6.7
Country of origin
Any other income and benefits

7.1
Chargeable event gains
7.2
7.4
Number of years
Other income and benefits (gross amount)
7.5
7.3
Tax treated as paid on box 7.1 income
7.6
Description of box 7.4 income, etc
8.3
Total of any 'one-off' payments included in box 8.1
Gift Aid
8.1
Gift Aid payments made in the year of claim
8.2
Gift Aid payments made in the year of claim but

treated as if made in the preceding year
R40(M)
8.4
Gift Aid payments made after the end of the year of

claim but to be treated as if made in that year
PAGE 3
Blind Person's Allowance

9.1
If you are registered blind (severely sight impaired)

with a local authority, or other register, put 'X' in the box
9.2
Enter the name of the local authority, or other register

(or 'Scotland' or 'Northern Ireland', as appropriate)
Please also consider box 10.6 below
Married Couple's Allowance

This allowance is only due if you, or your spouse or civil partner, were born before 6 April 1935. Read page 11 of the Notes.
10.1
To claim the full allowance, enter your spouses or civil

partners full name
10.2
If, as a couple, you have already asked us to give all of

the minimum amount to your spouse or civil partner,
put X in the box
10.3
10.4
Your spouses or civil partners date of birth if older than

you and you filled in boxes 10.1, 10.2 or 10.3
DD MM YYYY
10.5
Enter the date of the marriage or civil partnership

DD MM YYYY
10.6
Any unused Married Couples, or Blind Person's Allowance

can be transferred from one spouse or civil partner to the
other if you want us to send you a form to do this,
put X in the box or you can download it from
www.hmrc.gov.uk/forms/575-t-man.pdf and attach it to
this claim form.
If youve already agreed that half of the minimum amount

is to go to your spouse or civil partner, put X in the box
Repayment instructions
11.1
If the payable order is to be sent to your bank or building

society, fill in boxes 11.1, 11.3, 11.4, 11.5 and 11.6, if applicable
If you would like the payable order to go to your

UK bank, building society or any other nominee,
please enter in full the name, address and postcode
11.3
Branch sort code
11.2
11.4
Account number
11.5
Name of account holder
11.6
Bank or building society roll or reference number, if you

have one
If your nominee is your adviser, enter their reference
Declaration Please make sure that you have read the R40 Notes at section 12.2 before signing
12.1
Please sign and date this form and then write your full name (in capital letters) in the space provided
The information I have given on this form is correct and complete to the best of my knowledge.
Signature
Date
Name and title in capital letters

12.2
If you have signed on behalf of someone else, enter the

capacity, for example, parent, executor, receiver, attorney
R40(M)
12.3
PAGE 4
Tick this box if you do not need a claim form in future

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Claim for repayment of tax deducted

from savings and investments

How to fill in this form

This form is designed to be read by machine please follow

Please allow 4 weeks before contacting us about your

If you would like the payable order to go to your bank,

Date of birth DD MM YYYY

Your contact phone number(s)

National Insurance number

Name and address if it is different from above. Please

If this is an interim claim and you expect to receive more

UK employment income, pensions and state benefits

Total pay from all employments, before tax taken off

Tax taken off box 2.1 income

Total of other pensions and retirement annuities,

Tax taken off any taxable Incapacity Benefit included

State Pension enter the amount you were entitled to

Total of other taxable state benefits

If you do not receive State Pension, put X in the box

Tax taken off box 2.7

Additional information read page 3 of the notes

UK interest and dividends

Net interest paid by banks, building societies etc and

Tax taken off

Dividends from UK authorised unit trusts, open-ended

Gross amount the amount before tax taken off

UK company dividends (but do not add on the tax credit)

Stock dividends enter the appropriate amount in cash/

Trust, settlement and estate income

Please give the Unique Taxpayer Reference (UTR)

Net amount taxed at trust rate after tax taken off

Tax credit on box 4.8 income

Tax paid or tax credit on box 4.4 income

Income payments from settlor-interested trusts

Income taxed at 22% after tax taken off

Net amount of dividend income

Net amount of non-savings income after tax taken off

Tax paid or tax credit on box 4.6 income

Tax paid or tax credit on box 4.2 income

Net amount of savings income after tax taken off

UK land and property

Expenses allowable for tax

Land and property losses brought forward from

Foreign dividends (net amount)

Foreign tax taken off box 6.10 income

Foreign pensions and any other foreign income

Foreign property expenses allowable for tax

Foreign tax taken off box 6.8 income

Foreign property income before expenses

Foreign interest and other savings

Foreign tax taken off box 6.3 income

Foreign dividends eligible for tax credit (net amount)

Foreign tax taken off box 6.5 income

Foreign tax taken off box 6.1 income

Any other income and benefits

Chargeable event gains

Other income and benefits (gross amount)

Tax taken off box 7.4