Division Identification of the claim(s) [number]F1

Reference:

Nature of the claim(s) concerned:

1. □ a)

   customs duties

2. □ b)

   value added tax

3. □ c)

   excise duties

4. □ d)

   tax on income or capital

5. □ e)

   tax on insurance premiums

6. □ f)

   inheritance and gift taxes

7. □ g)

   national taxes and duties on immovable property, other than the abovementioned ones

8. □ h)

   national taxes and duties on the use or ownership of means of transport

9. □ i)

   other taxes and duties levied by or on behalf of the (applicant) State

10. □ j)

    taxes and duties levied by or on behalf of territorial or administrative subdivisions of the (applicant) State, excluding taxes and duties levied by local authorities

11. □ k)

    taxes and duties levied by or on behalf of local authorities

12. □ l)

    other tax-based claim

13. □ m)

    refunds, interventions and other measures forming part of the system of total or partial financing of the European Agricultural Guarantee Fund (EAGF) and the European Agricultural Fund for Rural Development (EAFRD), including sums to be collected in connection with these actions, and levies and other duties provided for under the common organisation of the market for the sugar sector

Name of the tax/duty concerned:

Period or date concerned:

Date of establishment of the claim:

Date on which enforcement becomes possible:

Amount of the claim still due:

1. □

   principal amount:

2. □

   administrative penalties and fines:

3. □

   interest till date before the day the request is sent:

4. □

   costs till date before the day the request is sent:

5. □

   fees for certificates and similar documents issued in connection with administrative procedures related to the tax/duty concerned:

6. □

   total amount of this claim:

Date of notification of the initial instrument permitting enforcement in the applicant State: (name of the applicant State):

1. □

   Date:

2. □

   No date available

Office responsible for the assessment of the claim:

• Name:

• Address:

• Other contact details:

• Language(s) in which this office can be contacted:

Further information concerning the claim or the possibilities for contesting the payment obligation can be obtained from:

1. □

   the office indicated above

2. □

   the following office responsible for the Uniform instrument permitting enforcement:

   • Name:

   • Address:

   • Other contact details:

   • Language(s) in which this office can be contacted: