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Form 481.0 - Individual Income Tax Return - Department Of Treasury Of Puerto Rico - 2010 Page 4

Taxpayer's Social Security Number

Form 481.0, Rev. 12.10 - Page 4

Part 5

Taxpayer's name ________________________________

AUTHORIZATION FOR DIRECT DEPOSIT OF REFUND

Routing/transit number

Your account number

Type of account:

Checking

Savings

and

Account in the name of

(Print complete name as it appears on your account. If married and filing jointly, include your spouse's name)

OATH

I hereby declare under penalty of perjury that this return, schedules and other documents attached, has been examined by me and it is true, correct and complete.

The declaration of the person that prepares this return (except the taxpayer) is based on the information available, and this information has been verified.

Taxpayer's Signature

Date

Spouse's Signature

Date

Specialist's Name (Print)

Name of the Firm or Business

Address

Registration Number

Employer Identification Number

Self - employed Specialist

Specialist's Signature

Date