Declaration to the Revenue Commissioners of Ireland And to the Department of Social Protection Authotisation Form PAYE A2

1. Authorisation to act as a ent I, Date of Birth : PPS Number : _________________________________ (first name, surname) _________________ __________________

authorise Mrs EVA KO NE!KA, "AIN #$%#$A, &ith an a''ress at Kerinsto&n, Ki((u)an, !o *estmeath to a)t as m+ a,ent in 'ea(in, &ith a(( as-e)ts of the fi(in, of m+ Irish in)ome ta. return, in)(u'in, the submission of refun' or )re'it )(aims,P SI refun', a((o&an)es or re(iefs// I )onfirm that this authorisation &i(( remain in for)e unti( e0enue is forma((+ notifie' of its )essation b+ either m+se(f or Mrs E0a Korne)1a/ !. Authorisation for A ent to receive refunds on "ehalf of client I authorise the transfer of an+ refun' or re-a+ment of PA2E3In)ome 4e0+35ni0ersa( So)ia( !har,e 'ue to me b+ the e0enue !ommissioners b+ e(e)troni) fun's transfer to the fo((o&in, ban1 a))ount &hi)h is he(' b+ EVA KO NE!KA: Ban1: AIB Mu((in,ar Sort !o'e: 6$7897#: A))ount Number: 8:;::<=# Name of A))ount >o('er: E0a Korne)1a I un'erstan' that an+ refun' ma'e b+ the e0enue !ommissioners to m+ a,ent, E0a Korne)1a, on m+ beha(f is refun'e' in a simi(ar manner as if same &ere bein, refun'e' 'ire)t(+ to me an' that on)e the refun' is transferre' into the ban1 a))ount nominate' b+ me I ha0e no further )a(( u-on the e0enue !ommissioners in res-e)t of same/ I un'erstan' that E0a Korne)1a is a)tin, as m+ a,ent an' is so(e(+ res-onsib(e to me in res-e)t of an+ refun' re)ei0e' b+ them on m+ beha(f/ I further un'erstan' that m+ a,ent E0a Korne)1a is an in'e-en'ent entit+ an' that the e0enue !ommissioners ma1e no en'orsement of m+ a,ent or an+ su)h a,en)+ an' )annot a))e-t an+ res-onsibi(it+ &hatsoe0er for -rob(ems en)ountere' b+ me in 'ea(in, &ith them/ I un'erstan' an' a,ree that the ?PA2E "a. A,en)+@ E0a Korne)1a &i(( in-ut its o&n ban1 a))ount 'etai(s on the e0enue re)or' for the 'uration of this man'ate an' &i(( remo0e these 'etai(s on the )essation of the man'ate/ I )onfirm that I am a&are of, an' a,ree to, the -a+ment of the fees )har,e' b+ the ?PA2E "a. A,en)+@ E0a Korne)1a in res-e)t of the ser0i)es )arrie' out on m+ beha(f an' that this fee &i(( be 'e'u)te' from an+ amount refun'e'/ 2. #erms and Conditions of Authorisation I un'erstan' that "a. (a& -ro0i'es for both )i0i( -ena(ties an' )rimina( san)tions for the fai(ure to ma1e a return, the ma1in, of a fa(se return, fa)i(itatin, the ma1in, of a fa(se return, or )(aimin, ta. )re'its, a((o&an)es or re(iefs &hi)h are not 'ue/ I )onfirm that I &i(( -ro0i'e the ne)essar+ 'o)umentation to Mrs E0a Korne)1a to su--ort an+ refun', )re'it )(aims or )(aims for a((o&an)es an' re(iefs ma'e to e0enue on m+ beha(f b+ Mrs E0a Korne)1a/ I )onfirm that I &i(( -ro0i'e 'etai(s of a(( m+ sour)es of in)ome to Mrs E0a Korne)1a/ I un'erstan' that Mrs E0a Korne)1a is reAuire' to retain a )o-+ of a(( 'o)umentation re(atin, to an+ refun' or )re'it or a((o&an)e or re(ief )(aime' b+ the a,ent on m+ beha(f an' that the a,ent &i(( be reAuire' to -ro'u)e same to e0enue u-on reAuest/ Si,ne':_______________________ !(ient Si,ne':_______________________ Date: ____________________

Date:____________________

A,ent