Salut,

i mulumim c ai ales RT Tax s i recupereze taxele din SUA!

Returnarea taxelor nu a fost niciodat mai uoar! Urmrete aceti pai:
LISTEAZ toate paginile acestui fiier
SEMNEAZ la semnul X
F O POZ sau SCANEAZ documentele de mai jos:
Formular de inregistrare
Power of Attorney/Agreement
Power of Attorney
Form 2848
Form 8821
Agreement

Le vei gsi n acest pachet

Formularul/formularele W-2 sau ultimul pay slip/urile (de la fiecare angajator)

Copie dupa card-ul tau Social Security
Copie dupa viza ta SUA din pasaport
Formularul DS-2019 (doar pentru deintori de viz J-1)

NOT: Chiar dac nu ai toate documentele necesare, poi s ncepi procesul de recuperare taxe. Vom obine
documentele lips pentru tine!

DEPUNE TOATE DOCUMENTELE LA RT TAX!

ncarc ONLINE pe www.rttax.com

Sau trimite e-mail pe usa@rttax.com
Sau adu sau trimite la biroul de reprezentan RT Tax

WORK AND TRAVEL CLUB

Bucureti
BLvd. Regina Elisabeta 7-9, et. 3, camera 6
Tel./Fax: +4 021 335 08 12
Mob. Tel: +4 0755 99 77 88
E-mail: info@workandtravelclub.ro
www.workandtravelclub.ro

RELAXEAZ TE! TU I-AI FCUT TREABA! DE RESTUL NE OCUPM NOI!

i trimitem un e-mail cu suma returnabil calculat etimativ (Dac nu primeti acest e-mail, te rugm
s ne contactezi pe info@rttax.com sau online pe www.rttax.com).

Noi procesm documentele tale i le trimitem la Autoritile Fiscale din SUA pentru
recuperarea taxelor.
Dup ce taxele tale ni s-au returnat, noi i transferm banii n contul tu bancar.

Procedura de returnare in SUA incepe la sfarsitul anului financiar, in 1 ianuarie.

TRADITIONAL: Perioada de rambursare ine de obicei de la 90 pn la 120 de zile de la

momentul n care primim documentele.

RAPID:
Perioada de rambursare ine de obicei de la 35 pn la 45 de zile. Ca s
aplici pentru recuperare rapid bifeaz pe formularul de nregistrare!
EXPRES:

Perioada de rambursare ine de obicei de la 5 pn la 7 de zile. Ca s aplici

pentru recuperare de expres bifeaz pe formularul de nregistrare!

NOT: Documentele ncrcate online sau trimise prin e-mail sunt procesate mai repede!

ONLINE

Work and Travel Club

USE ENGLISH LETTERS PLEASE!
First (Given) Name:

DANIELA

Middle Name:

ELENA

Surname (Last Name):

SCINTEIE
Home tel.:

Date of birth:

19 9
_ 2
_ / _0 _7m / 0_ 6_ d

E-mail address:

danutsaa06@yahoo.com

Refund Type

REGULAR

Social Security Number:

Arrival to the USA date:

X
5

FAST

Mob tel.:

+40758608430

EXPRESS

7 m /2_ 0_ d
2 01
_ 4
_y/0
_ _

0
2 01
_ 4
_ y /1
_ 0
_ m /3_ 0_ d

Leaving the USA date:

For what year(s) do you want to claim your TAX Refund with RT Tax?

2014
Yes

Did you apply for the same tax refund that you are applying now at another company or by yourself earlier?

How many employers did you have:

No

WI

What State have you worked in:

You must list ALL THE EMPLOYERS (even if you did not pay taxes in that job) and provide THE LAST PAY-SLIPS or W-2 FORMS.
If you do not have them, we will help you to get them.

1. Company: Birchwood Lodge

15071 Wisconsin 57, Sister Bay, WI 54234

2. Company: Al Johnson's Swedish Restaurant Butik

10698 N Bay Shore Dr Sister Bay, Wisconsin 54234
Address:

920-854-7195

Tel/Fax:

Address:
Tel/Fax:
E-mail:

I have W2 form or last pay-slip from this job

If NO, I want RT Tax to get replacement YES

920-854-2626

E-mail:
YES

NO
X
NO

Client notes:

I have W2 form or last pay-slip from this job

If NO, I want RT Tax to get replacement

YES

YES

NO

NO

3. Company:
Address:
Tel/Fax:
E-mail:
I have W2 form or last pay-slip from this job

RT Tax notes:

Income:

If NO, I want RT Tax to get replacement

YES

YES

NO
NO

4. Company:
Taxes paid:

Address:
Tel/Fax:
E-mail:
I have W2 form or last pay-slip from this job
If NO, I want RT Tax to get replacement

By signing this form I declare that all the information,

Signature:

supplied by me on this form is correct and complete.

Date:

YES

YES

NO
NO

POWEROFATTORNEY
DANIELA ELENA SCINTEIE
1992-07-06 (the Principal) hereby authorises
..................................................................................................................,
personal ID No / date of birth ................................
UABA&ZGroup,companycode302522637,officeaddressatLaisvesAl.67,Kaunas,Lithuania,itsmanagersand/oremployees(theAgent)

toperformanyandallactionsrequiredfortheproperperformanceoftheAgentsobligationsundertheCollectionAgreementexecutedwiththePrincipal,i.e.
including,butnotlimitedto:

(i)toreceivethechequesdrawnforthebenefitofthePrincipalandinthenameofthePrincipalorinthenameoftheAgent(theCheques)fromanypersons;
(ii)tocollecttheChequesinthebankaccountoftheAgent;
(iii)toreceiveonbehalfofthePrincipalamountstransferredbythirdparties;
(iv) to transfer the amounts received after collection of Cheques or received directly from the third parties to the Principal by a bank transfer, by issuing a
chequeorinanyotherwayifitsagreedbythePrincipalandtheAgent;
(v)fromtheamounttobetransferredtothePrincipaltodeductthefeepayabletotheAgentundertheCollectionAgreementandtheamountofservicefee
payabletoTorusSolutionNV,undertheServicesAgreementexecutedbetweenthePrincipalandTorusSolutionNV;
(vi) to prepare, sign, submit and receive all and any documents related to the above mentioned assignments, and to perform all and any other actions in
connectionwiththeforegoing.

TheAgentshallbeentitledtodelegatepowersgrantedhereundertoanythirdperson.ThisPowerofAttorneyshallbevalidfor2(two)years fromitsexecution.

Date:__________________________
ThePrincipal(signature):___________________________________
X

CollectionAgreement
Place:.....................................

Date:....................................

ThisCollectionServicesAgreement(theAgreement)isexecutedbyandbetween:
(1)
UABA&ZGroup,companycode302522637,LaisvesAl.67,Kaunas,Lithuania(theAgent),email:info@turbotransfers.com,and

DANIELA ELENA SCINTEIE

1992-07-06
(2)
.............................................................................................................................................................,dateofbirth.........................................(thePrincipal).
HereinaftertheAgentandthePrincipaltogetherarereferredtoasthePartiesandeachseparatelyastheParty.
RECITALS
(A)
ThePrincipalandTorusSolutionNVhaveexecutedtheServicesAgreement,pursuanttowhichTorusSolutionNVshallprovidereceivablesadministrationservices(the
Receivables)inaccordancewiththeServicesAgreement.ReceivableswillberefundedtothePrincipalinaformofcheque(chequeswillbedrawninthenameofthe
PrincipalortheAgent,whoprovideschequescollectionandrelatedservices(theCheque),asthenomineeofthePrincipal)orbyadirectbanktransfer;
(B)
ThePartieswishtoagreeonthetermsandconditionsofthecollectionoftheCheque;
(C)
ForthepurposesofimplementationofthisAgreement,theAgentwillusethepersonaldata,bankaccountdetailsandotherinformationofthePrincipalsubmittedtothe
Agent.
1.
Subjectmatter
1.1.
InaccordancewiththetermsandconditionssetinthisAgreement,theAgentshallprovidetothePrincipalchequescollectionandrelatedservices(theServices)andthe
PrincipalshallacceptandremunerateforsuchServices.
2.
TermsofProvisionofServices
2.1.
ThePartiesagreethattheAgentwillactandshallbeindicatedinallrelateddocumentsasthenomineetoreceivetheChequeand/orotherkindsofpaymentsonbehalfof
thePrincipal.
2.2.
OncetheChequeisreceivedbytheAgent,hewillsubmitthechequeforcollectiontoanybankselectedbytheAgent.Thesubmissionshallbemadenotlaterthanwithin
15(fifteen)daysfromthereceiptoftheChequeorotherreceivables.
2.3.
TheChequeorotherpaymentsreceivedshallbecollectedontheseparatebankaccountoftheAgent.Thecollectedmoneyand/oramountsreceivedfromthethirdparties
shallbeaccountedseparatelyfromthefundsoftheAgentinaseparateaccount.ThePartiesagreethattheseamountsareownedbythePrincipalandareheldinthe
account of the Agent for the benefit of the Principal in accordance with this Agreement until the transferof the amountsdue to the Principal in accordance with this
Agreement.TheseamountsshallnotbeconsideredastheincomeoforasotherwiseownedbytheAgentand,unlessagreedotherwise,theAgentshallnotbeentitledto
usethecollectedmoneyforhisownneeds.
2.4.
Ifaccordingtothisagreement,thePrincipaldoesnotproviderequiredPrincipalspersonaldataincludingbankaccountinformationforcompletionoftheServiceswithin1
(one)yearfromthedatetheCollectionAgreementwassigned,theAgentshalldeductitsservicefeeand(ifapplicable)additionalbankchargesunderSection2.6(ii)and
shalltransfertheremainingamount(s)toTorusSolutionNVbankaccount.ThisshallbetreatedasproperandfullperformanceoftheobligationsoftheAgentsetinthe
AgreementandtheAgentshallnotbeheldliableforanyfurtherclaimsagainsttheamountsconcerned.
2.5.
The money received after collection of the Cheque or received directly from any third parties shall be refunded to the Principal after deduction of the Service Fee in
accordancewithSection3.1,3.2hereof,andtheservicefeepayablebythePrincipaltotheTorusSolutionNVundertheServicesAgreementand(ifapplicable)additional
bankchargesunderSection2.6(ii),byabanktransferorbyabankchequedrawninthenameofthePrincipalorhis/hernominee.
2.6.
TheAgentshallbearthecostofonebanktransfer.However,theAgentshallnotberesponsiblefor(i)anyfeeschargedbythePrincipalsbankorintermediarybank;or(ii)
foranyadditionalbankchargesifthebankneedstorepeatthetransferbecauseoftheincorrectorincompleteinformationprovided.Wherethereceivableamountis
convertedfromonecurrencytoanother,itshallbecalculatedinaccordancewiththeexchangerateappliedbytherespectivebankvalidonthedayofconversionforthe
purposesofthebanktransfertobemadetothePrincipalsbankaccount.TheAgentshallbearthecostofthecurrencyconversion.
2.7.
WhileprovidingtheServicestheAgentshallasnecessarydisclosethatheisactingasthenomineeofthePrincipalandthecollectionoftheChequeorotherpayments
receivedandtransferofmoneyismadeinthenameandonbehalfofthePrincipal.
3.
TheServicesFees
3.1.
ThefeefortheServices(theServiceFee)shallbeafixedamountofUSD20(twenty)plusVAT(ifapplicable)foronetransferandUSD5(five)plusVAT(ifapplicable)for
eachchequeissuedtothePrincipalinaccordancewiththetermsandconditionsofthisAgreement.
3.2.
The Service Fee shall be deducted from the amount received after collection of the Cheque or from the other payments received, prior to the transferring it to the
Principalsbankaccountorissuingthecheque.
4.
ValidityoftheAgreement
4.1.
TheAgreementshallcomeintoforceuponsigningofitbybothPartiesandshallbevaliduntiltheproperandfullperformanceoftheobligationsofthePartiessetinthe
Agreement.
4.2.
TheAgreementmaybeterminatedbythemutualagreementoftheParties.
4.3.
ThePrincipalshallhavetherighttounilaterallyterminatetheAgreementonlypriortoTorusSolutionNVhasstartedimplementingagreedconditionsdescribedinthe
Services Agreement, by informing the Agent in accordance with Section 5.3 hereof. After Torus Solution NV activities has been started, the Agent will complete the
provisionsoftheServiceshereunder,totheextentpossible,andshallhavearighttomakethedeductionsinaccordancewithSection2.5and(ifapplicable)Section2.6
hereof.
5.
Miscellaneous
5.1.
This Agreement is executed in English. The electronic copy of the Agreement shall be provided to the Principal at his request after it is executed by the Agent. All
amendmentstotheAgreementshallbevalidiftheyareinwritingandsignedbybothParties.
5.2.
TheAgreementshallbegovernedbytheLithuanianlaw,andanydisputearisingfromorinconnectionwiththeAgreementshallberesolvedbythecourtoftheRepublicof
Lithuania.
5.3.
AllnoticesandothercommunicationunderthisAgreementshallbeinwritingandshallbehandedinpersonorsentbyregularmail,emailorfaxtotheaddressesofthe
Agentprovidedabove,andtotheaddressesofthePrincipalprovidedbytheTorusSolutionNVundertheServicesAgreement.

Principal
Agent

_____________________________________

______________________________________
X

POWER OF ATTORNEY
DANIELA ELENA SCINTEIE
I, the undersigned.............................................................,
1992-07-06
854176060
date of birth ..,
Social Security number .............,
residing at
Starda Bujorului, nr. 57 Braila
...................................................................
(hereinafter referred to as the Principal), hereby grant a power of attorney to the company, UAB Rinkos Tinklas,
its officers and/or employees with its registered address at Laisves Al. 67, Kaunas, Lithuania (hereinafter referred to
as the Agent), to sign, verify and file all the principals federal, state, social security and medicare, local income and
other tax returns; examine and copy all the principals tax returns and records; represent the principal before any
federal, state or local revenue agency or taxing body and, in general, exercise all powers with respect to tax matters
which the principal could, if present and under no disability.
On the basis of this power of attorney UAB Rinkos Tinklas its officers and/or employees are given the authority:
1. To act as an agent in preparing and dealing with the Principals income tax return(s) for the tax years 20092014.
2. To use own postal address on the Principals tax return(s).
3. To receive all correspondence from the IRS and State Tax Authorities.
4. To request from the Principals employer(s) and to receive Principals W2 form to the address:
15W700 N Frontage Rd. #222, Burr Ridge, IL 60527, USA

Signed this ....... day of ...., 20............

X
Signature of the Principal:

Form

2848

(Rev. July 2014)

Department of the Treasury
Internal Revenue Service

Part I

OMB No. 1545-0150

Power of Attorney
and Declaration of Representative
a

For IRS Use Only

Received by:

Information about Form 2848 and its instructions is at www.irs.gov/form2848.

Name

Power of Attorney

Telephone

Caution: A separate Form 2848 must be completed for each taxpayer. Form 2848 will not be honored
for any purpose other than representation before the IRS.

Function
Date

Taxpayer information. Taxpayer must sign and date this form on page 2, line 7.

Taxpayer name and address

Taxpayer identification number(s)

854

DANIELA ELENA SCINTEIE

17

6060

Daytime telephone number

Plan number (if applicable)

hereby appoints the following representative(s) as attorney(s)-in-fact:

2

Representative(s) must sign and date this form on page 2, Part II.

Name and address

UAB RT, P/D 219

Kaunas LT-44001, LITHUANIA
Check if to be sent copies of notices and communications

CAF No.
PTIN
Telephone No.
Fax No.
Check if new: Address

Telephone No.

Fax No.

Telephone No.

Fax No.

Telephone No.

Fax No.

Telephone No.

Fax No.

CAF No.

Name and address

Check if to be sent copies of notices and communications

630-390-2242
630-390-2242

PTIN
Telephone No.
Fax No.
Check if new: Address
CAF No.
PTIN

Name and address

Telephone No.
(Note. IRS sends notices and communications to only two representatives.)

Fax No.
Check if new: Address
CAF No.
PTIN

Name and address

Telephone No.
(Note. IRS sends notices and communications to only two representatives.)

Fax No.
Check if new: Address

to represent the taxpayer before the Internal Revenue Service and perform the following acts:
3
Acts authorized (you are required to complete this line 3). With the exception of the acts described in line 5b, I authorize my representative(s) to receive and
inspect my confidential tax information and to perform acts that I can perform with respect to the tax matters described below. For example, my representative(s)
shall have the authority to sign any agreements, consents, or similar documents (see instructions for line 5a for authorizing a representative to sign a return).
Description of Matter (Income, Employment, Payroll, Excise, Estate, Gift, Whistleblower,
Practitioner Discipline, PLR, FOIA, Civil Penalty, Sec. 5000A Shared Responsibility
Payment, Sec. 4980H Shared Responsibility Payment, etc.) (see instructions)

Individual Income Tax

Tax Form Number

(1040, 941, 720, etc.) (if applicable)

1040EZ, 1040NR-EZ, 1040NR, 4852

FICA Tax

843, 8316

State Income Tax

Year(s) or Period(s) (if applicable)

(see instructions)

2014, 2013, 2012, 2011

2014, 2013, 2012, 2011
2014, 2013, 2012, 2011

Specific use not recorded on Centralized Authorization File (CAF). If the power of attorney is for a specific use not recorded on CAF,
a X
check this box. See the instructions for Line 4. Specific Use Not Recorded on CAF . . . . . . . . . . . . . . .

5a

Additional acts authorized. In addition to the acts listed on line 3 above, I authorize my representative(s) to perform the following acts (see
instructions for line 5a for more information):
Authorize disclosure to third parties;
Substitute or add representative(s); X Sign a return; This Power of Attorney is being filed
pursuant to Regulations section 1-6012-1(a)(5) by reason of my continuous absence from the United States.

Other acts authorized:

For Privacy Act and Paperwork Reduction Act Notice, see the instructions.

Cat. No. 11980J

Form 2848 (Rev. 7-2014)

Page 2

Form 2848 (Rev. 7-2014)

Specific acts not authorized. My representative(s) is (are) not authorized to endorse or otherwise negotiate any check (including directing or
accepting payment by any means, electronic or otherwise, into an account owned or controlled by the representative(s) or any firm or other
entity with whom the representative(s) is (are) associated) issued by the government in respect of a federal tax liability.
List any specific deletions to the acts otherwise authorized in this power of attorney (see instructions for line 5b):

Retention/revocation of prior power(s) of attorney. The filing of this power of attorney automatically revokes all earlier power(s) of
attorney on file with the Internal Revenue Service for the same matters and years or periods covered by this document. If you do not want
to revoke a prior power of attorney, check here . . . . . . . . . . . . . . . . . . . . . . . . . . a

Signature of taxpayer. If a tax matter concerns a year in which a joint return was filed, each spouse must file a separate power of attorney
even if they are appointing the same representative(s). If signed by a corporate officer, partner, guardian, tax matters partner, executor,
receiver, administrator, or trustee on behalf of the taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer.

YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.

IF NOT COMPLETED, SIGNED, AND DATED, THE IRS WILL RETURN THIS POWER OF ATTORNEY TO THE TAXPAYER.

X
Signature

Date

Title (if applicable)

X
Print Name

Part II

Print name of taxpayer from line 1 if other than individual

Declaration of Representative

Under penalties of perjury, by my signature below I declare that:

I am not currently suspended or disbarred from practice before the Internal Revenue Service;
I am subject to regulations contained in Circular 230 (31 CFR, Subtitle A, Part 10), as amended, governing practice before the Internal Revenue Service;
I am authorized to represent the taxpayer identified in Part I for the matter(s) specified there; and
I am one of the following:
a Attorneya member in good standing of the bar of the highest court of the jurisdiction shown below.
b Certified Public Accountantduly qualified to practice as a certified public accountant in the jurisdiction shown below.
c Enrolled Agentenrolled as an agent by the Internal Revenue Service per the requirements of Circular 230.
d Officera bona fide officer of the taxpayer organization.
e Full-Time Employeea full-time employee of the taxpayer.
f Family Membera member of the taxpayers immediate family (for example, spouse, parent, child, grandparent, grandchild, step-parent, stepchild, brother, or sister).
g Enrolled Actuaryenrolled as an actuary by the Joint Board for the Enrollment of Actuaries under 29 U.S.C. 1242 (the authority to practice before
the Internal Revenue Service is limited by section 10.3(d) of Circular 230).
h Unenrolled Return PreparerYour authority to practice before the Internal Revenue Service is limited. You must have been eligible to sign the
return under examination and have prepared and signed the return. See Notice 2011-6 and Special rules for registered tax return preparers
and unenrolled return preparers in the instructions (PTIN required for designation h).
i Registered Tax Return Preparerregistered as a tax return preparer under the requirements of section 10.4 of Circular 230. Your authority to
practice before the Internal Revenue Service is limited. You must have been eligible to sign the return under examination and have prepared and
signed the return. See Notice 2011-6 and Special rules for registered tax return preparers and unenrolled return preparers in the
instructions (PTIN required for designation i).
k Student Attorney or CPAreceives permission to represent taxpayers before the IRS by virtue of his/her status as a law, business, or accounting
student working in an LITC or STCP. See instructions for Part II for additional information and requirements.
r Enrolled Retirement Plan Agentenrolled as a retirement plan agent under the requirements of Circular 230 (the authority to practice before the
Internal Revenue Service is limited by section 10.3(e)).
a

IF THIS DECLARATION OF REPRESENTATIVE IS NOT COMPLETED, SIGNED, AND DATED, THE IRS WILL RETURN THE
POWER OF ATTORNEY. REPRESENTATIVES MUST SIGN IN THE ORDER LISTED IN PART I, LINE 2. See the instructions for
Part II.
Note. For designations d-f, enter your title, position, or relationship to the taxpayer in the "Licensing jurisdiction" column. See the instructions for Part II
for more information.

Designation
Insert above
letter (ar)

Licensing jurisdiction
(state) or other
licensing authority
(if applicable)

Bar, license, certification,

registration, or enrollment
number (if applicable).
See instructions for Part II for
more information.

Signature

Date

Form 2848 (Rev. 7-2014)

Form

8821

(Rev. October 2011)

Department of the Treasury
Internal Revenue Service

OMB No. 1545-1165

Tax Information Authorization

For IRS Use Only

Received by:
Name

a Do

not sign this form unless all applicable lines have been completed.
a Do not use this form to request a copy or transcript of your tax return.
Instead, use Form 4506 or Form 4506-T.

Telephone
Function
Date

1 Taxpayer information. Taxpayer(s) must sign and date this form on line 7.
Taxpayer name(s) and address (type or print)

Taxpayer identification number

854

DANIELA ELENA SCINTEIE

17

6060

Daytime telephone number

Plan number (if applicable)

2 Appointee. If you wish to name more than one appointee, attach a list to this form.
CAF No.
Name and address
PTIN
Telephone No.
+370-676-22176
UAB RT, P/D 219
Fax No.
+370-676-22176
Kaunas LT-44001, LITHUANIA
Check if new: Address
Telephone No.
Fax No.
3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information in any office of the IRS for the
tax matters listed on this line. Do not use Form 8821 to request copies of tax returns.
(a)
Type of Tax
(Income, Employment, Excise, etc.)
or Civil Penalty
Individual Income Tax
FICA Tax

(b)
Tax Form Number
(1040, 941, 720, etc.)
1040EZ, 1040NR-EZ, 1040NR, 4852
843, 8316

(c)
Year(s) or Period(s)
(see the instructions for line 3)

(d)
Specific Tax Matters (see instr.)

2013, 2012, 2011, 2010

2013, 2012, 2011, 2010
2013, 2012, 2011, 2010

State Income Tax

4 Specific use not recorded on Centralized Authorization File (CAF). If the tax information authorization is for a specific
use not recorded on CAF, check this box. See the instructions on page 4. If you check this box, skip lines 5 and 6
. . a
5 Disclosure of tax information (you must check a box on line 5a or 5b unless the box on line 4 is checked):
a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing
basis, check this box
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
Note. Appointees will no longer receive forms, publications and other related materials with the notices.
b If you do not want any copies of notices or communications sent to your appointee, check this box . . . . . . . a

6 Retention/revocation of tax information authorizations. This tax information authorization automatically revokes all prior
authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do not want
to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain in effect
and check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
To revoke this tax information authorization, see the instructions on page 4.
7 Signature of taxpayer(s). If a tax matter applies to a joint return, either husband or wife must sign. If signed by a
corporate officer, partner, guardian, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify
that I have the authority to execute this form with respect to the tax matters/periods on line 3 above.
a IF

NOT SIGNED AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED.

a DO

NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.

X
Signature

Date

Signature

Date

X
Print Name

Title (if applicable)

Print Name

PIN number for electronic signature

For Privacy Act and Paperwork Reduction Act Notice, see page 4.

Title (if applicable)

PIN number for electronic signature

Cat. No. 11596P

Form 8821 (Rev. 10-2011)

(1)
(2)

(A)
(B)
1.
1.1.

1.2.
1.3.

1.4.
2.
2.1.

2.2.

3.
3.1.

3.2.

3.3.
3.4.
3.5.
4.
4.1.

4.2.

5.
5.1.

6.
6.1.

ThisServicesAgreement(theAgreement)isexecutedbyandbetween:

Date:...............................
TorusSolutionNV(dbaRTTax),companycode126057,representedbythepersondullyauthorizedunderexistinglegislation(theServiceProvider);and

DANIELA ELENA SCINTEIE

1992-07-06
....................................................................................................,dateofbirth.........................................(theClient).
HereinaftertheServiceProviderandtheClienttogetherarereferredtoasthePartiesandeachseparatelyastheParty.
RECITALS
TheServiceProviderprovidestaxrefundandrelatedservicesandtheClientwishestorecoverthepersonalincometaxpaidduetoworkabroadoronothergrounds.
ThePartieswishtoagreeonthetermsandconditionsoftaxrefund.
Subjectmatter
InaccordancewiththetermsandconditionssetinthisAgreement,theServiceProvidershallprovidetotheClienttaxrefundandrelatedservices,i.e.shalldrawupthedocuments
necessaryfortherefundofthetaxespaidbytheClientintheUnitedStatesofAmerica,UnitedKingdom,Ireland,theNetherlands,Germany,Norway,Canada,NewZealand,
Australia or other jurisdiction and shall present them to the corresponding tax authorities or other competent institutions (the Services), and the Client shall accept and
remunerateforsuchServices.
By this Agreement the Client authorises the Service Provider to prepare, sign and file tax returns and to receive all correspondence, including tax refund cheques, from tax
authorities.ServiceProviderwillasnecessarydisclosethatheisactingasthenomineeoftheClientandalltheactionsaremadeinthenameandonbehalfoftheClient.
TaxeswillberefundedtotheClientbyabanktransferoftherefundedamounttothebankaccountorbyabankchequedrawninthenameofthenomineeindicatedbytheClient.
TheTaxRefundChequeshallbecollectedandthetaxrefundamountshallbetransferredtotheClientbytheCollectionServicesProviderinaccordancewiththetermsand
conditionssetintheCollectionAgreementexecutedbetweentheClientandtheCollectionServicesProvider.
The final amount of the taxes to be refunded shall be established by a competent institution of the foreign country. The amounts calculated by the Service Provider are for
informationpurposesonlyanddonotentitletheClienttoclaimthepreliminarilycalculatedamount.
TermsofProvisionofServices
TheServiceProviderherebyundertakes:
2.1.1.
toprovidetheClientinformationonthedocumentsthattheClientneedstosubmittotheServiceProviderforthepurposesoffilingforthetaxrefund;
2.1.2.
tocollect,completeandsignalltherequiredforms,requestsandotherrelateddocumentsonbehalfoftheClient;
2.1.3.
tosubmittherequireddocumentstotherespectivetaxauthoritiesorothercompetentinstitutionsthatareresponsiblefortaxrefunds;
2.1.4.
toinformtheClientabouttheprocessofthetaxrefundandotherrelatedmattersattheClientsrequest;
2.1.5.
totransfertheTaxRefundChequetotheCollectionServicesProviderforcollectionundertheCollectionAgreementexecutedbetweentheClientandtheCollection
ServicesProviderortoinstructthetaxauthoritytotransferthetaxrefundamounttotheCollectionServicesProviderforsubsequenttransferoftaxrefundamount
totheClient.
TheClientherebyundertakes:
2.2.1.
toprovidetotheServiceProvidercomplete,trueandaccurateinformationanddocuments(originalsandcopies)requiredforthecompletionofthetaxrefund.The
ClientisentitledtoprovidetheinformationeitherbyfillinginpaperformsprovidedbyServicesProviderorbyfillingintheonlineinformationformavailableatthe
ServiceProvidersinternetsite;
2.2.2.
tofillinandsignanyformsandotherdocumentsrequiredforthecompletionofthetaxrefund;
2.2.3.
toinformtheServiceProviderimmediatelyandinallcasesnotlaterthanwithin5(five)days,iftheforeigntaxorotherauthoritytransferstherefundedamountor
apartthereoforsendstheTaxRefundChequeforthefullrefundamountorapartthereofdirectlytotheClient;
2.2.4.
duringthevaliditytermofthisAgreementtoabstainfromexecutingtaxrefundservicesagreementswithotherserviceproviders;
2.2.5.
toinformtheServiceProviderofthenewemploymentorselfemploymentinaforeigncountry;
2.2.6.
toinformtheServiceProviderofanychangesintheClientscontactdetailsoraboutanyotherchangesthatmayhaveimpacttothetaxrefund.Theinformationcan
beupdatedontheinternetsiteoftheServiceProvideroremailed;
2.2.7.
topaytheServiceProvidertheServiceFeeassetoutinSection3hereof.
TheServicesFees
ThefeefortheServices(theServiceFee)forrefundingtaxesforeachtaxyearshallbe:
3.1.1.
FortheREGULARUSAtaxrefund(FederalandState),ifthetaxrefundamountisbetweenUSD0200,theservicefeeshallbeUSD50;USD201600,theservice
feeshallbeUSD70;USD601800,theservicefeeshallbeUSD80;USD801andmore,theservicefeeshallbe10%fromtherefundedamount.
AdditionalFeesappliesfortheFast33USDandfortheExpress99USDUSAtaxrefund.FastandExpressisavailableforFederalandStatetaxrefundonly.
3.1.2.
3.1.3.
USAtaxrefund(SocialSecurityandMedicare):theservicefeeshallbe10%fromtherefundedamount,withafixedminimumofUSD90;
3.1.4.
UnitedKingdom,ifthetaxrefundamountisbetweenGBP0100,theservicefeeshallbeGBP35;GBP101200,theservicefeeshallbeGBP50;GBP201600,the
servicefeeshallbeGBP55;GBP601andmore,theservicefeeshallbe11%fromtherefundedamount.
3.1.5.
Ireland:theservicefeeshallbe11%fromtherefundedamountwithafixedminimumof60EUR;
3.1.6.
Irelandtaxrefund(UniversalSocialCharge(USC)):theservicefeeshallbe11%fromtherefundedamountwithafixedminimumof60EUR;
3.1.7.
Norway:theservicefeeshallbe14%fromtherefundedamount,withafixedminimumofEUR80;
3.1.8.
TheNetherlands:theservicefeeshallbe11%fromtherefundedamountwithafixedminimumofEUR49;
3.1.9.
TheNetherlandssocialsecurity(Zorgtoeslag)refund:theservicefeeshallbe15%fromtherefundedamountwithafixedminimumofEUR49;
3.1.10.
Germany:theservicefeeshallbe14%fromtherefundedamountwithafixedminimumofEUR50;
3.1.11.
Canada:theservicefeeshallbe11%fromtherefundedamount,withafixedminimumof70CAD;
3.1.12.
NewZealand:theservicefeeshallbe14%fromtherefundedamount,withafixedminimumof135NZD;
3.1.13.
Australia:theservicefeeshallbe10%fromtherefundedamount,withafixedminimumof105AUD;
Theadditionalfees:FortheretrievalofthelostormissingdocumentsshallbeforW2(USA)USD15,P45/P60(UnitedKingdom)GBP15,P60(Ireland)EUR17,T4(Canada)
CAD15,RF1015B(Norway)EUR17,Jaaropgaafform(theNetherlands)EUR17,Lohnsteuerkarte(Germany)EUR17,SummaryofEarnings(NewZealand)45NZD,
PaymentSummaryPAYGform(Australia)AUD30.ForfillingtheUSAamendedtaxreturn(Form1040X)thefeeis50USD.
TheClientshallalsocompensatethefeesandcostsincurredbytheServiceProviderinthetaxrefundprocessthatcouldnotbeforeseenatthemomentoftheexecutionofthis
AgreementaslistedinthepricelistoftheServiceProvider.
TheamountofthepayableVAT(ifapplicable)shallbeaddedtoallamountsindicatedinSections3.13.3hereof.ThefeesestablishedinSections3.13.2maybechangedbythe
ServiceProviderunilaterallyandshallbeapplicabletoanyrequestoftheClienttoprovidetheServicessubmittedaftertheClienthasreceivednoticeonthechangeoffees.
TheServiceFeeshallbedeductedfromtheamountreceivedafterthetaxrefundpriortothetransferringittotheClientsaccount.
Liability
IftheClientterminatestheAgreementfortheotherreasonsthanfailurebytheServiceProvidertoperformitsobligationsafterthefilingforthetaxrefundisdoneorincaseof
breachofobligationssetoutinSection2.2.4hereof,theClientshallpaythefineofUSD100andshallcoverallexpensesoftheServiceProviderincurredduetothetermination
oftheAgreement,notcoveredbythefine.
TheServiceProvidershallnotbeliablefor:thedelaysinrefundingtaxesifthedelayiscausedbytheforeigntaxorothercompetentinstitutions;thefailuretorefundtaxes,forthe
taxliabilityorforanyothernegativeconsequences,whichoccurredduetofalse,inaccurateorincompleteinformationprovidedbytheClientorduetoClientspriorfinancial
commitments to any foreign tax or other institutions; the negative consequences incurred by the Client due to the changes in the applicable laws, rules, regulations or
proceduresapplicableforthetaxrefund;additionalbankcharges,ifthebankneedstorepeatthetransferbecauseoftheincorrectornotfullinformationprovided;andany
feeschargedbytheClientsorintermediarybank.
ValidityoftheAgreement
The Agreement shall come into force upon signing of it by both Parties and shall be valid until the proper and full performance of the obligations of the Parties set in the
Agreement.TheAgreementmaybeterminatedbythemutualagreementoftheParties.TheClientshallhavetherighttounilaterallyterminatetheAgreementpriortothefiling
fortaxrefundbyinformingtheServiceProviderinaccordancewithSection6.1hereof.
Miscellaneous
Alladditions,amendmentsandannexestotheAgreementshallbevalidiftheyareexecutedinwritingandsignedbybothPartieswithoutprejudicetoSections3.13.4hereof.The
electronic copyof the Agreement shall be provided to the Principal at hisrequest after it is executed by the Agent. The disputes arising between the Partiesregarding this
AgreementorduringtheperformanceofthisAgreementaresettledbywayofnegotiations.Incaseoffailuretocometoanagreement,thedisputesshallbefinallysettledby
thecompetentcourt.AllnoticesandothercommunicationunderthisAgreementshallbeinwritingandshallbehandedinpersonorsentbyregularmail,emailorfax.

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