7/18/2019 Wage Tax Statement 2001

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Belastingdienst / Tax Authorities Individual Wage Tax Statement For 2001 and following years

1 Your personal details

 Are your details completed already? Please check them and amend if necessary.

Name and initials

EMPLOYEE NUMBER Address

Zip code andresidence

Date of birth Sofi-number

Starting datePlease enter the date when this wage tax statement commences (see the explanation). 

2 Wage tax credits or not with this employer

Please complete the scheme below. Or tick the box nearby if you choose not to completethe scheme. Please go to point 3 (also read the explanation).

  You choose that this employer

does not apply the tax credit.

Only one employer at the same time can apply for the tax credit. Please follow thescheme to determine whether the employer who provided you with this form should applythe tax credit.

Do you have anotheremployer, besides theemployer who gave you

this form?

Yes Does the other employerapply the tax credit?

Yes Tick the box:  The employer who gave you

this form should NOT apply thetax credit.

No NoTick the box:

The employer who gave you this form should apply the taxcredit.

3 Signature

Please return this form after signing to your employer.

Date Signature

Space reserved for your employer

To be completed by your employer

Employer

Payroll Tax number Tax credit code   0   1