Model Statement of Data for Payroll Taxes

Your employer or benefits agency must withhold wage tax and national insurance contributions also known as payroll tax (loonheffing: loonbelasting/premie volksverzekeringen) on your wages or benefit payment. This is why your  employer or benefit agency needs your data. Use this form to provide the data.

You also use this form to tell us whether you want your employer or benefits agency to apply the payroll tax credit (loonheffingskorting). If they apply this tax credit, you pay less payroll tax. You can have the payroll tax credit applied by only 1 employer or benefits agency.

You can also use this form if your employer or benefits agency already applies the payroll tax credit and you want to stop this.

Complete and submit

You can fill in the form on the computer. You need Adobe Reader 9.0 or higher. Once you have duly completed the form, you can print it and sign it.

Please submit the completed and signed form to your employer or benefits agency before your fist working day. If you are starting work on the same day your employer hired you, submit this statement before starting work. If you receive a benefit payment, you must submit this form before the fist payment.

Problems with completing the form?

It is best if you complete the form on a computer. We cannot guarantee a proper functioning on a tablet or smartphone.

If you are unable to complete the form on your computer, you should first save the form. You can do so by right-clicking on the link of the form and selecting 'Save target' (this term may differ per browser).