
Extract the fields along with their values using the format <filed name> : <field value> from the following form.

“Your Charter” explains what you can expect from us and what we expect from you. For more information, go to www.worddox.orgAbout You
1. Surname: NAME_1 4. National Insurance Number
2. First name: NAME_2 5. Self-Assessment reference
3. Address: 302 N. Columbia Street,Chapel Hill 27516 About your repayment 6. Employer PAYE reference [if applicable]
7. Tell us the dates that you want to claim the repayment of overpaid tax From: ……………..............................To…………………………………… 11. Tell us the bank or building society details Name of account holder or holders Name………………………………………………………………………………… Bank or building society account number Branch sort code Address of bank or building society Signature: Date: DD/MM/YYYY
8. Who do you want to receive the amount due? 1. Yourself 2. Agent 3. Nominee [Tick 1 box] If an agent, give their reference …………………………………………………………………........... Write your response with exactly 6 paragraphs, separated with the markdown divider: ***.
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