To HM Revenue & Customs 

## Authorisation Please Use Capital Letters


  

  

As a director/beneficial shareholder of the company named above I understand that: - the company has made an application to have its Construction Industry Scheme payments 
paid gross under Section 63, Finance Act 2004 
- HM Revenue & Customs (HMRC) have made a direction that in dealing with this application they 
will consider whether the directors/beneficial shareholders have complied with the conditions 
set out at Paragraph 4, Part 1, Schedule 11, Finance Act 2004. 


  

  

If HMRC are of the opinion that I have not complied with all the conditions set out at Paragraph 4 
Part 1, Schedule 11, Finance Act 2004, I authorise HMRC to disclose this to the company secretary. 


I understand that HMRC may refer to any of my failures to fulfil the conditions in any appeal proceedings before the Tribunal. I authorise HMRC to do this. 

Director's/beneficial shareholder's name Director's/beneficial shareholder's Unique Tax Reference (UTR) 
 
National Insurance number Put 'X' in one or both boxes, whichever *applies* 
 
 
I am a director and/or a beneficial shareholder of the company named above Signature 
 
Company name 


Company Unique Tax Reference (UTR)