1N – Claim Form for Repayment of Jamaican Income Tax

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