Health Expenses - Claim For Relief Page 2

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Income Details of Claimant
PPS No.
Please enter details of income that was subject to PAYE in the year of claim. These details are available on your Form P60 or, if
relevant, your Form P45. In the absence of your Form P60/P45, the relevant details may be obtained from your employer/pension
provider. If you, your spouse or civil partner had more than one employment or Private Pension please list the total taxable Pay
& Tax deducted and Gross Pay for USC & USC deducted for each employment or pension on a separate sheet. Alternatively,
include your P60 for each employment or P45 if not already submitted. Please note that incomplete forms will result in a
delay in finalising your claim.
Self
Spouse or Civil Partner
Name of Employer or Pension Provider
Total Taxable Pay
€
€
Total Tax deducted
€
€
Gross Pay for USC
€
€
Total USC deducted
€
€
Total Income from other sources not subject to PAYE
€
€
(see ‘Income from other sources’ section on Page 4)
Details of Claim
Maintenance or treatment in an approved nursing home (see ‘Nursing Homes’ section on Page 3)
(1)
€
Nursing Home
Name and Address
Non-Routine Dental Treatment (per Med 2) (see ‘Receipts’ section on Page 3)
(2)
€
Routine Health Expenses (see ‘Qualifying Medical Expenses’ section on Page 3)
(a) Services of a doctor or consultant
€
(b) Total outlay on prescribed drugs or medicines for the year
€
(c) Educational Psychological Assessment for a dependent child
€
(see note on Page 3)
(d) Speech and Language Therapy for a dependent child
€
(see note on Page 3)
€
(e) Orthoptic or similar treatment
(on referral from a doctor or other qualifying practitioner)
€
(f) Diagnostic procedures (X-rays, etc.)
€
(g) Physiotherapy or similar treatment
(on referral from a doctor or other qualifying practitioner)
€
(h) Expenses incurred on any medical, surgical or nursing appliance
€
(i) Maintenance or treatment in a hospital
(j) Other Qualifying Expenses (provide brief details below)
€
Total
(a) to (j)
(3)
€
TOTAL HEALTH EXPENSES
€
(1 + 2 + 3)
Deductions -
(if none write ‘NONE’)
Sums received or receivable in respect of any of the above expenses
(i) from any public or local authority, for example, Health Service Executive
€
(ii) under any policy of insurance, for example, VHI, Laya Healthcare, Aviva Health, etc.
€
(iii) other, for example, compensation claim
€
TOTAL DEDUCTIONS
€
AMOUNT ON WHICH TAX RELIEF IS CLAIMED
€
(Total Health Expenses less Total Deductions)
Page 2

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