FORMULARZ zgłoszenia podatku do zwrotu

FORMULARZ zgłoszenia podatku do zwrotu Prosimy używać drukowanych iter IMIĘ I NAZWISKO UK ADRES NARODOWOŚĆ NR NATIONAL INSURANCE ADRES W POLSCE TEL. KONTAKTOWY MIEJSCE URODZENIA DATA URODZENIA CZY JESTEŚ ZAMĘŻNA/ŻONATY TAK NIE E-MAIL ADRES DATA ŚLUBU DATA URODZENIA ŻONY/MĘŻA IMIĘ NAZWISKO MAŁŻONKA Prosimy podać następujące informacje DATA PRZYBYCIA DO UK DATA WYJAZDU Z UK (ub panowana data wyjazdu) DATA ROZPOCZĘCIA I ZAKOŃCZENIA PRACY U OSTATNIEGO PRACODAWCY W UK CZY KIEDYKOLWIEK ODZYSKIWAŁEŚ PODATEK W UK? JEŚLI TAK TO ZA KTÓRY ROK PODATKOWY? TAK NIE Historia zatrudnienia w UK (proszę podać dane oraz kresy pracy u wszystkich pracodawców w UK) Data rozpoczęcia Data zakończenia Dane pracodawcy (nazwa, adres, teefon) Prosimy wybrać sposób przekazania zwrotu Przeew na konto... BANK NR KONTA Prosimy przesłać formuarze oraz pity na adres Mój Londyn A. Słowackiego 17a/415 31-159 Kraków Data i podpis Odbiór osobisty w biurze... Wyrażam zgodę na przetwarzanie moich danych osobowych do ceów związanych z reaizacją zwrotu podatku

Leaving the United Kingdom Tax reference Nationa Insurance number Pease use these references if you write or ca. It wi hep to avoid deay. Issued by Teephone IR138 Living or retiring abroad encosed Income Tax caim when you have eft or are about to eave the UK If you need hep with this form, or you are not sure whether it appies to you, pease read the tes on the back. To caim tax reief, or repayment of UK income tax, pease answer a the questions in order, passing over those questions where you are directed to another section compete Section 6 if appropriate, and Section 7 in a cases, making sure that you sign and date the sections take a copy of the competed form in case we need to refer you to it, and return the origina to the above office. Section 1 Residence detais Compete ALL parts of this section What is your nationaity? On what grounds do you caim this nationaity? Which country are you going to? Give your address abroad if you know it When did you eave, or when are you eaving, the UK? Enter Day, Month, Year How ong were you iving in the UK before the date you eft or date you intend to eave? Do you intend to ive outside the UK permanenty? If, do you intend to ive outside the UK for a fu tax year starting on 6 Apri after your departure? if aso to the above, when do you expect to return to the UK? Wi you be visiting the UK whie you are iving abroad? If, what periods do you expect to spend in the UK over the next 3 years? Are you eaving the UK to work? If go to Section 2 If give your reason for eaving the UK in the box, and go to Section 3. P85 BMSD 2/00

Section 2 Empoyment detais Compete ALL parts IF you are eaving the UK to work What type of job is it? Enter your empoyer s name and address enter the name of your department if you are empoyed by the UK Government. Wi you be working fu-time? Do you have a separate contract for your work abroad? If how ong is the contract for? Wi any of your work be carried out in the UK? If give detais of the work you wi be doing in the UK. Is your work abroad done on a days on/ days off rota? If give detais, incuding where you expect to spend the days off. Enter the name of the town or city, and country. In what currency wi you be paid for your work abroad? Where wi you receive your earnings? Country Country where (Bank) Account hed Currency Currency If any part of your pay is to be paid through an office or agent in the UK, give the fu name and address of the payer. Name Section 3 Accommodation detais Compete ALL parts uness you are directed to another Section Wi you or, if you are married, your wife/husband have any accommodation in the UK whie you are away? If go to Section 4 If give detais of the kind of accommodation it is for exampe house, fat, etc., and enter its address. Description If you eft the United Kingdom after 5 Apri 2000, go to Section 4. Do you own or have you ever owned the accommodation described above? If go to Section 4 If pease tick one box to show whether the property is soey owned or jointy owned Do you intend to return to the property as your soe or main residence within four years of the date of your departure?

Do you have a mortgage or other oan on this property? If go to Section 4 If give detais of oan and ender Name of ender Mortgage or Loan account number Branch address Amount of Loan or Mortgage outstanding Is your mortgage or oan in the Mortgage Interest Reief at Source (MIRAS) scheme so that you pay oan interest net of tax reief? Section 4 Further property detais Compete ALL parts uness you are directed to another Section Wi you be receiving rents, premiums, or other income from any property in the United Kingdom? If go to Section 5 If pease tick one box to show whether the property is soey owned or jointy owned How much income from etting wi you receive each year? Give an estimate if you do not know the precise amount. In the year of your departure In the foowing year Wi you be receiving the income direct either into your UK bank account or overseas? If give detais of the person who wi be paying you. Name Wi you be receiving the income through an agent who manages the property for you? If give detais of the agent or if the agent ives outside the UK detais of the payer. Date agent began managing the property Agent/ Payer Section 5 Other detais Answer ALL the questions in this Section Wi you have any other source of income in the United Kingdom after you have eft? If give detais Do you have ife insurance poicies that were taken out before 14 March 1984? Any entitement to pay premiums net of tax reief may be affected when you move abroad. If give detais of the poicy, and a premiums you wi continue to pay after eaving the UK Name of the insurer Poicy number Did you notify your insurance companies of your date of departure from the UK? Premiums payabe in the year to 5.4.

Do you have a persona pension? If give detais of a Name of persona pension scheme contributions you wi continue to pay after eaving the UK Contract number Did you notify your persona pension provider of your date of departure from the UK? Contributions payabe in the year to 5.4. Section 6 Repayment caim and payment authority Compete uness directed to Section 7 If you are being sent abroad by your present empoyer, any repayment of tax you are due wi be deat with through your empoyer s Inand Revenue office, go to Section 7. I caim repayment of tax that I may be entited to for the year ending on 5 Apri, and encose Parts 2 and 3 of my P45 Detais of empoyee eaving work. Pease enter your address in the box beow. Any repayment wi be made direct to you at that address uness you te us otherwise. If you want your repayment made to a nominee, compete the remaining boxes in this Section as we. You may have your repayment made to your bank or buiding society, or to any other person on your behaf, in the United Kingdom, or to branches of certain banks or a company set up by a UK bank, in the Irish Repubic, the Ise of Man, or the Channe Isands. Your address Name of nominee Enter the account detais where the nominee is a bank or buiding society Branch Sort Code Account number I authorise repayment to be made to the person, bank or buiding society shown above. Signature Date Section 7 Decaration You can be prosecuted if you give fase information The information I have given on this form is correct and compete to the best of my knowedge and beief. Signature Date Print your fu name Pease enter here a teephone number incuding diaing code at which we can contact you with any questions. tes Broady, if you are resident in the United Kingdom you wi pay UK tax on a your income. If you are not resident you wi pay UK tax ony on income arising in the UK. You wi be not resident if, for exampe you wi be iving and working fu-time in another country for at east a fu tax year, and your visits back to the UK wi tota ess than 183 days in any specific tax year, and average ess than 91 days a tax year. You can find more information in booket IR20 Residents and n-residents Liabiity to tax in the United Kingdom, avaiabe from any Inand Revenue Enquiry Centre or Inand Revenue office. If you need hep competing this form, contact the Inand Revenue office shown on the front. If you are eaving the UK to work abroad, and you or your empoyer require advice about your Nationa Insurance iabiity contact: Nationa Insurance Contributions Office, Internationa Services, Empoyers Unit, Longbenton, Newcaste Upon Tyne, NE98 1ZZ. Date Initias For use in the Inand Revenue office Copy to Centra Unit MIRAS Miras 80 to Centra Unit if appropriate Date Initias Persona pensions Life Assurance Paragraph 14 tice to S/M tice to S/A tice to P.H. tice to L.O.

Arriva in the United Kingdom Pease use these if you write or ca. It wi hep to avoid deay. Tax reference Nationa Insurance number Issued by As you have come to the United Kingdom (UK) for the first time, or after a period of absence, we need some information from you. It is important that you compete this form so that we can make sure you pay the right amount of tax. Pease print your fu name Pease show your Nationa Insurance number, if you know it, uness it is aready shown in the above reference. The HMRC website contains information on residence, ordinary residence and domicie that you may find hepfu: www.hmrc.gov.uk/cnr A Residence and Ordinary Residence Pease answer a of the foowing questions 1 When did you arrive in the UK? 2 a. Why have you come to the UK, for exampe, empoyment? how much time in each year of your stay here do you intend spending outside the UK? 3 If you visited the UK during the 5 years before the date of arriva, approximatey how many compete days did you spend in the UK b. Do you intend to stay permanenty in the UK? c. If you answer '' to question 2b how ong do you intend staying, for exampe ess than 2 years, 2 to 3 years, 3 years or more? a. in each year ending on 5 Apri? b. for the tax year of arriva, in the period between 6 Apri and the date you entered at 1? P86 HMRC 04/06 1

4 a. Have you, your spouse or your civi partner had any accommodation of any description for your use in the UK from the date you arrived in the UK? b. If you answer '' to question 4a what is the address? d. Have you retained a residentia property in that country? 6 a. What is your date of birth? b. If you have a spouse or civi partner what is his or her date of birth? in what capacity have you occupied the accommodation, for exampe, owner, tenant, empoyer provided? if owned, on what date was the accommodation purchased? on what date did you marry or form a civi partnership? 7 a. Where and for whom did you work during the five years before your arriva in the UK? c. if it is rented what is the period of the tenancy agreement? what was the date of the agreement? If you have hed accommodation at more than one address, pease give the detais for each, on a separate sheet or in the Additiona Information box on page 4. b. When did each empoyment begin and end? Continue in the Additiona Information box on page 4 if necessary B Income Tax Aowances and Liabiities 5 a. What is your nationaity? b. On what grounds do you caim this nationaity? c. In which country were you resident before your arriva in the UK? c. Were any duties of these empoyments performed in the UK? If '' pease give detais on page 4 in Additiona Information 2

d. Has the most recent of these empoyments continued (on eave or otherwise) since you arrived in the UK? e. If you answer '' when is this empoyment ikey to end? f. If you answer '' and you are in empoyment, what is the name and address of your empoyer in the UK? Name/ 10 a. Do you have income arising abroad (other than from the Repubic of Ireand) or gains on assets situated outside the UK which wi not be whoy paid to the UK? b. If you answer '' pease state the main source of income (for exampe, pension, bank interest, royaties, dividends) or capita gains, and the country in which it arises. 11 Have your costs, or those of your famiy, in traveing between the country in which you normay ive and the UK, been borne or reimbursed by your empoyer? C Reevance of Domicie Domicie is a concept of genera aw. It is different from residence and ordinary residence. It is ony necessary to consider your domicie if this is immediatey reevant to deciding your iabiity to UK Income Tax and Capita Gains Tax. Answer a of the foowing questions uness otherwise directed. 8 Wi you have income from empoyment: where the empoyer is not resident in the UK, and a duties of the empoyment wi be carried out abroad, and you do not expect to remit a the income to the UK? 9 a. Are you (or wi you be) making a caim for UK tax reief for contributions to a non-uk pension scheme or retirement benefit pan which are incurred out of remuneration you receive from an empoyer who is not resident in the UK? b. If you answer '' what is the name of the pension scheme or retirement benefit pan. If you answer '' to ALL questions 8 to 11 domicie is not immediatey reevant in deciding your iabiity to UK Income and Capita Gains Tax. You shoud go to Part E. 12 Do you caim to be not domicied in the UK? If you answer '' go to Part E, if continue with the questions beow 13 a. Were you born outside the UK? b. If you answer '' in which country were you born? 14 Have you come to the UK for the soe purpose of empoyment (incuding sef-empoyment)? If you answer to both questions 13a and 14 pease go to Part D. If you answer to either questions 13a or 14 pease ask your HM Revenue & Customs office for form DOM 1 and go to Part E. c. Date joined 3

D Domicie Information Compete this Part ony if you have answered '' to any of questions 8 to 11. 15 Where was your father domicied at the date of your birth (in the case of a country with a federa system, pease show the particuar state or province)? Present address If appropriate, pease print the fu name and address of your present empoyer 16 Where do you consider you are domicied and on what grounds (in the case of a country with a federa system, pease show the particuar state or province)? Name Additiona Information 17 a. What are your intentions for the future? b. If you do not intend to stay permanenty in the UK, when and in what circumstances do you envisage that your residence wi cease? E Decaration I decare that I wi notify the HM Revenue & Customs without deay if there is a change in my circumstances or intentions which woud affect any of the answers given the information I have given in this form is correct and compete to the best of my knowedge and beief. Signature Date Pease return this form to the HM Revenue & Customs Office that sent it to you. 4

=DZDUWDSRPLG]\ 802:$325('1,&7:$ Mój Londyn Artur Kubica $O6áRZDFNLHJRDSRN 31-159 Kraków NIP: 675-112-03-92 REGON: 356684758 Z\VWSXMF\GDOHMMDNR0yM/RQG\Q a... ]DPLHV]NDá\DZ...... te....z\vwsxmf\mdnr=ohfhqlrgdzfd 1. Ja... XSRZD*QLDP 0yM /RQG\Q GR Z\VWSRZDQLD MDNR SRUHGQLN Z WUDNFLH RG]\VNLZDQLD SRGDWNX dochodowego za prace wykonane w Wiekiej %U\WDQLL3RGSLVDáHPGRNXPHQW3 2. =OHFHQLRGDZFD RZLDGF]D *H Z\SHáQLá IRUPXODU] ]JáRV]HQLRZ\ L SRGSLVDá GRNXPHQW\ 3 RUD] ]DSR]QDá VL ]H VWDQGDUGDPL ]ZURWX podatku z Wiekiej Brytanii. 3. =OHFHQLRGDZFDRZLDGF]D*HZFLJXGQLRG GDW\ SRGSLVDQLD QLQLHMV]HM XPRZ\ SU]HOH QD adres biura Mój Londyn w Krakowie dokumenty, RNWyU\FKPRZDZSXQNFLHZUD]]]DáF]RQ\P dokumentem P45 i/ub P60 (ub paysip), wraz ] GZRPD HJ]HPSODU]DPL Z\SHáQLRQHM L podpisanej umowy. 4. Mój Londyn pobiera 15% prowizji od kwoty RG]\VNDQHJRSRGDWNXDOHQLHZF]HQLHMQL*SR jego odzyskaniu. Tym samym Mój Londyn RZLDGF]D *H QLH SRELHU]H *DGQ\FK RSáDW W\WXáHP SRUHGQLFWZD GR PRPHQWX RG]\VNDQLD SRGDWNX-H*HOLNZRWDSURZL]MLQLHSU]HNURF]\ *%3 0yM /RQG\Q SRELHU]H SURZL]M Z Z\VRNRFL *%3 UH]\JQXMF ] SURZL]ML :DUWRü *%3 MHVW OLF]RQD ZHGáXJ NXUVX VNXSX RERZL]XMFHJR Z EDQNX REVáXJXMF\P 0yM /RQG\Q QD G]LH SU]HOHZX QD NRQWR 0yM /RQG\Q 3URZL]MD OLF]RQD MHVW áf]qlh ]D wszystkie ata podatkowe. Prowizja zawiera podatek VAT. 5. 0yM/RQG\QZFLJXGQLURERF]\FKRGPRPHQWX otrzymania przeewu podatku na konto Mój /RQG\Q Z\SáDFL NZRW RG]\VNDQHJR SRGDWNX Zeceniodawca SRPQLHMV]RQHJR R SURZL]M QD NRQWR Zeceniodawcy. 6. =OHFHQLRGDZFD MHVW ]RERZL]DQ\ GR QLH]ZáRF]QHJR LQIRUPRZDQLD 0yM /RQG\Q R wszekiej otrzymanej z Wiekiej Brytanii NRUHVSRQGHQFML ]ZL]DQHM ]H ]ZURWHP SRGDWNX : SU]\SDGNX RWU]\PDQLD RG XU]GX VNDUERZHJR (Inand Revenue) zwrotu podatku w postaci czeku i samodzienej reaizacji tego czeku SU]H] =OHFHQLRGDZF =OHFHQLRGDZFD MHVW ]RERZL]DQ\ GR XLV]F]HQLD SURZL]ML ZHGáXJ RWU]\PDQHM IDNWXU\ ZHGáXJ NXUVX EDQNX REVáXJXMFHJR 0yM /RQG\Q QD G]LH ]ár*hqld czeku do inkasa ub jego skupu. 7. =OHFHQLRGDZFD ]RERZL]XMH VL QLH Z\VWSRZDü VDPRG]LHOQLH OXE ]D SRUHGQLFWZHP RVyE trzecich, o zwrot podatku przed brytyjskim XU]GHP VNDUERZ\P Z F]DVLH RERZL]\ZDQLD niniejszej umowy. 8. 1LQLHMV]D XPRZD Z\JDVD Z PRPHQFLH Z\SáDW\ SRPQLHMV]RQHJR R SURZL]M SRGDWNX =OHFHQLRGDZF\ RUD] ]DSáDW\ SURZL]ML GOD 0yM Londyn, ub z innych przyczyn XQLHPR*OLZLDMF\FK RG]\VNDQLH SRGDWNX L QLH Z\QLNDMF\FK ] ZLQ\ 0yM /RQG\Q 0yM /RQG\Q MHVW ]RERZL]DQ\ XGRNXPHQWRZDü RGPRZ ]ZURWX SRGDWNX SU]H] XU]G :LHONLHM %U\WDQLL 1LQLHMV]D XPRZD ]RVWDáD ]DZDUWD Z GZyFK jednakowych egzemparzach, po jednym da ND*GHM]HVWURQ 9. =OHFHQLRGDZFD Z\UD*D ]JRG QD MHGQRUD]RZH Z\VWDZLHQLH IDNWXU\ EH] SRGSLVX ]ZL]DQHM ] naiczeniem prowizji. Za Mój Londyn... Data... Podpis... Podpis