household charge form - an post

8/2/2019 Household Charge Form - An Post

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H O U S E H O L D C H A R G E D E C L A R A T I O N A Household ChargeHC12N NEW ACCOUNT REGISTRATION FORM

Funding your local serv ices

A. PPSN/TRN of Residential Property Owner (See Note A)P P S N is requi red fo r ident i f ica t ion purposes

If your country of residence is side the Republ ic of Ireland and.you do not have a PPSN/TRN please tick this boxB. Residential Property Owner Details (See Note B) P L E A S E U S E B L O C K C A P I T A L L E T T E R S

rst Nam e Surname

C o mpany N a m e(I f Appl icable)

Company Contact:First Name

N o

No

Surname

Box(es) i f you DO NOT wish to receive reminder notifications:numbe rs a re co l lected i f vo lunta r i l y submit ted fo r ann ua l rem inders

addres s is requi red to i ssue receipt & d i rect debi t not i fica t ionus ed in future years to not i fy proper ty o wners l iab i li t y fo r Hou seho ld Charge

DBy Mobile DBy Emai l

QUESTION - P l e a s e C h o o s e one quest ion (See Note C) P L E A S E U S E B L O C K C A P I T A L L E T T E R S(a ) What is your Mother's maiden name?(c ) Where w ere yo u born?

(b ) What is your pet 's name?(d ) Where is your company based?

FOR OFFICE USE ONLYHC Account Ref Code: H C BUREAU STAMP & DATE

Payment Code ID:

LO G N U MBE R :

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D . PROPERTIES T O B E REGISTERED - P L E A S E U SE B L O C K C A P I T A L L E T T E R SIf property address to be registered is s a m e as correspondence address tick this boxProperty 1Address

Household ChargeFunding your local serv ices

County

County/CityCouncilProperty Type Qj House DApartmentW as this your property on 1January 2012?

DBedsitye s DNo (SeeNoteD)

Water Supply Connection: What type of water supply connection does your property have?[~| Public Main OPrivate Well E] Nopiped water supply Group Water SchemeGroup nameW a t e r C o n n e c t io n & P r o p e r t y t y p e are accomm odation, facil it ies and s e r v i c e s data r e q u i r e d for national databas e of residential prope rtiesWaiver: Are you entitled to awaiver from payment of the Household Charge? [~~| ye s |~| NO (See Note D)If Yes,please select waiver type: QMortgage Interest Supplement DUnfinished Housing Estate

Property 2Address

PLEASE U S E B L O C K C A P I T A L L E T T E R S

CountyCounty/CityCouncil

Property Type l~l House l~~l Apartment l~l BedsitW as this yojjL property on 1January 2012? DYesWater Supply Connection: What type of water supply connection does your property have?DPublic Main DPrivate Well DNo piped water supplyGroup name

DNo (See NoteD)Group Water Scheme

Waiver: A re you entitled to awaiver from payment of the HouseholdCharge? Qyes QNo (See NoteD)If Yes, please select waiver type: QMortgage Interest Supplement DUnfinished Housing Estate

(I f more than 2 propertiesto be registered - please ad d additional form HC12A)E . DECLARATION & SIGNATU RE (See Note E ) - 1 declare that the property/properties hereby being registered is/are liable to the

Household Charge and that the informationprovided is correct.Property Owner/Agent Signature ' Date Page 2 of 5


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. PAYMENT DETAILS - Payment must be in EURO (See note F)

! Household ChargeFunding your local services

or Bank Draf t Payment Payable to "Household Charge"

Cheque DBank Draf tCheque Number Bank Sort Code

Order Payment Payable to "Household Charge"

Postal Order Number

Payment

Amount

Amount

DVisa Mastercard Laser

Card Number

Expiry Date

Cardho lder Name

Cardholder Signature

Amount

F O R O F F I C E U S E ONLY

Receipt Number:

Batch Reference:

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A HouseholdChargefunding your local services

Notes for Completion of Household Charge Registration Form - HC12NIn completing the form, use CAPITAL LETTERS. Write clearly and accuratelywithin the boxes. DO NOT join your writing.A -PPSN/TRN:If your country of residence isoutside the Republic of Ireland and you do not have a PPSN/TRN please tick the box toconfirm this.PPSN (also known as RSI number) is unique to each individual and is used to distinguish between individuals with similarnames or addresses. The PPSN is usually identified on tax and welfare statements and P60s. If you do not have a PPSNplease contact your local Department of Social Protection office. Use of the PPSN is governedby law. The PPSN Code ofPractice is available from the Department of Social Protection and on their website (www.welfare.ie).TR N - Any company registered in Ireland automatically becomes liable for tax and therefore has a tax reference number.

B - RESIDENTIAL PROPERTY OWNER DETAILS:Please make sure to enter a correspondence address aswhen your form is processeda receipt will be posted to this address.If you represent a company or organisation please enter the CompanyName and contact name for the company.If the property is ointly owned, payment by any one co-owner discharges the liability of all co-owners. Please providedetails of only ONE owner.

C - S E C U R I T Y QUESTION:The security question is designed to protect the information provided by you and it may be requested in the future to verifyyotfr identity.D - PROPERTIES TO BEREGISTERED:Please select "Yes" or "No" beside the question - Was this property your property on the 01/01/2012Please indicate what type of water supply each property has - Connection to a: Group Scheme,Public Main, Private Wellor no piped water supply.

WAIVE R SMortgage Interest SupplementThe legislation provides that an owner of residential property who is entitled to receive mortgage interest supplement inrespect of that residential property on the liability date (1January) isentitled to a waiver from payment of the HouseholdCharge in respect of that property for that year. Please note that such persons must complete the declaration to claim thewaiver.Please note that all waiver claimswill be validated against the data held by the Department of Social Protection. Personswho make false or misleading declarations may be liable to penalties under the legislation.If you are unsure as to your entitlement to mortgage interest supplement, please contact your local Community WelfareOfficer, Department of Social Protection. Contact details are available from;http://www.welfare.ie/EN/ContactUs/Pages/cwo_contact.aspxUnfinished HousingEstateshe legislation provides that an owner of residential property which is situated in an unfinished estate, within the

meaning contained in the Local Government (HouseholdCharges) Act 2011, on the liability date (1January) is entitled to awaiver from payment of the Household Charge in respect of that property for that year. Please note that such personsmust complete the declaration to claim the waiver.

If you are unsure as to your entitlement to claim a waiver under this provision, please contact;UHE (Unfinished Housing Estate)Name Of Section: Planning & HousingPolicy Section, Department of Environment, Community & Local GovernmentCon tac t N u m b e r s : 053-9117397, 053-9117398, 053-9117399, 053-9117402Email Address: Planning&HousingOenviron.ieDetails of estates: www.householdcharge.iePlease note that all waiver claims will be validated against the data held by the Department of the Environment, Communityan d Local Government. Persons who make fa lse or misleading declarations may be liable to penalties under the legislation.

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Household ChargeFunding your local services

- DECLARATION & SIGNATURE:declaration form must be signed by the owner (or one owner if property is jointly owned) of the property or by his/ her

- PAYMENTDETAILS:d charge payable in 2012 is 100 per residential property. Payment types include Cheque, Bank Draft andOrder made payable to 'Household Charge'.Credit/Debit Card payment is also accepted. Only EURO payments will

that if a household charge is not paid on or before the 31 March, a late payment fee and late paymentwill apply during the period that the household charge remains unpaid. The late payment fees and late paymentwhich apply are set out in paragraphs a) and b) below

Late Payment F ee(i) 10% of the amount outstanding in respect of the unpaid household charge if paid not later than 6 months after the due dater(ii) 20% of the amount outstanding in respect of the unpaid household charge if paid later than 6 months and not later than 12

the due dater(iii) 30% of the amount outstanding in respect of the unpaid household charge if paid later than 12 months after the due datend

Late Payment Intereston the amount outstanding in respect of unpaid household charge is calculated at the rate of 1 percent per month or

of a month from the due date, until payment of the household charge hasbeen madeNOTES:

the form please ensure that you have included the following information:if applicable

Details of properties to be registeredhave signed and dated the declarationhave enclosed the correct payment or have provided the payment details in Section F.Please ensure all loose sheets are stapled together

T H E ABOVE INFORMATION IS REQUIRED TO PROCESS YOUR FORM. INCOMPLETE FORMSWILL BE RET URNED TO YOU.Please post completed form to : Household Charge, PO Box12168, Dublin 1

NOTE: Alternatively to Register Online go to www.householdcharge.ieTo contact the Household Charge Support Centre: Lo-call 1890-357357.

Payments can be made in your County/City Council office for a 3 month period from 1s t January to 31stMarch 2012 during normal office

OTE: Registration data collected by the Household Charge (HC) will be used in accordance with the provisions of the Local(Household Charge) Act 2011 and any other relevant legislation.

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household charge form - an post

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