The declaration referred to in section 848C(h) is a declaration in writing made by the qualifying individual to the qualifying savings manager which -
(a) is made and signed by the qualifying individual,
(b) is made in such form -
(i) as may be prescribed or authorised by the Revenue Commissioners, and
(ii) which contains a reference to the offence of making a false declaration under section 848T,
(c) contains the qualifying individual's -
(i) name,
(ii) address of his or her permanent residence,
(iii) PPS Number, and
(iv) date of birth,
(d) declares that at all times in the period from which the account was commenced until the date the declaration is made, the qualifying individual -
(i) was the beneficial owner of the qualifying assets held in the account,
(ii) had only one special savings incentive account,
(iii) was resident or ordinarily resident in the State,
(iv) subscribed to the account from funds available to the qualifying individual or his or her spouse without recourse to
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