Application to have Deposit Interest paid without deduction of DIRT
where applicant and/or Spouse or Civil Partner is aged 65 or over
Please read the explanatory notes overleaf before completing this form
Full Name of Applicant
Date of Birth
Spouse or Civil Partner Details
Full Name of Spouse
or Civil Partner
Date of Birth
Please complete a separate form for each account you and/or your Spouse or Civil Partner hold.*
Name of Branch/Office
Address of Branch/Office
Eircode (if known)
Account Details *Account may be with your Bank, Building Society, Credit Union or Post Office Savings Bank.
Account/Membership (Credit Union) Number
Date Received Stamp
Name of Account Holder(s)
Bank Identifier Code (BIC) (if applicable)
(Max. 11 characters)
International Bank Account Number (IBAN)
(Max. 34 characters)
I/We declare that I/We am/are beneficially entitled to the interest in respect of the account above and that:
I and/or my Spouse or Civil Partner am/are aged 65 years or over during the year, and
My/Our total annual income does not exceed the exemption limit for the year 2016 of
€18,000 for Single People or Widowed Persons or Surviving Civil Partners.
€36,000 for Married Couples or Civil Partners (combined income).
These limits are increased if you have dependent children - see overleaf for full details.
I/We undertake to advise the Financial Institution of any change in circumstance that may affect my/our eligibility
to have interest paid on my/our account without deduction of DIRT.
This is a form authorised by the Revenue Commissioners. It may be subject to inspection by Revenue. It is an
offence to make a false declaration.
Signature of Applicant (Account Holder)
Signature of Spouse or Civil Partner
(Joint Account only) (if applicable)