Child Tax Sample Form
Name of Claimant
Address of Claimant
PPS Number of Claimant
Name
Nature of Incapacity
Is the incapacity permanent? (Tick
as appropriate)
PPS Number
RPC004084_EN_WB_L_1
Date of Birth
D D
M M Y Y Y Y
Yes No
Claimant Details
Was the incapacity present since birth? (Tick
as appropriate)
Yes No
If not, state date of diagnosis
D D
M M Y Y Y Y
Is any other person entitled to claim for the same child? Yes No
If yes, state
Name and address
of other claimant
PPS Number of other claimant,
if known
Relationship to child
The yearly amount contributed by others towards the maintenance of the child
The yearly amount contributed by you towards the maintenance of the child
€ 0 0
.
,
€ 0 0
.
,
CLAIM FOR INCAPACITATED CHILD TAX CREDIT
Under Section 465 Taxes Consolidation Act 1997
Details of Incapacitated Child
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Child Tax Sample Form PDF
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