Individual Financial Statements

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Client Name

Please check your email address for errors

Phone (Business or Home)

Phone (Mobile)

Fax

Balance Date

Records Required

Wages/National Superannuation/Benefits

Please provide us with the names of any organisations you have received the following from:

Wages

ACC Payments

National Superannuation

Any other benefits

In most cases IRD will have sent us these details direct, however we do need to check all details have been included.

Student Loan

Do you have a student loan? Yes No

If yes, please provide your latest statement from IRD

Interest and Dividends

Please supply the advice slips.

For interest received, you should have an annual advice notice showing the withholding tax deducted. This may be on the bottom of your bank statement dated 31 March

If any dividends are taken as bonus shares, also include these advice slips

Advice Slips

Rental and Leased Property

Please complete a Rental Questionnaire as well

Partnerships, Trusts, Estates and Companies

Please supply details of income earned from any entity for which we do not prepare the accounts and tax returns.

Overseas

Supply details of overseas interest, dividends, wages received and taxation paid

Provide details of any overseas investments held at any time during the financial year

Attach all of your investments advisor's reports

Have you at any point in your lifetime, ever contributed to a foreign superannuation scheme, even if you cannot receive the benefits until you retire? Yes No

If yes, please provide details

Any Other Income

Please attach the following:

Income Replacement Insurance Policy

Please provide details of premiums and claims

Look Through Company

If you have been allocated a share of a loss other than from a company that we are aware of, please provide details

Did you receive non-taxable income from any other sources? Yes No

If yes, please provide details

Do you want us to complete your rebate claim form? Yes No

If yes, please attach receipts

Working for Families Tax Credits and Parental Tax Credit

Have you received Working for Families Tax Credits and/or Parental Tax Credit Yes No

Please supply full names and birth dates of all children. Please note the following:

• If you had a child born within the current financial year you may be eligible for the Parental Tax Credit. Please include their IRD Number below. If you do not have this you will need to obtain one for them in order to claim any entitlement for them

• Where a child has become financially independent during the current financial year, please advise the date they left school or home

Child's Name

IRD Number

Date of Birth

Date Left School

Child's Name

IRD Number

Date of Birth

Date Left School

Child's Name

IRD Number

Date of Birth

Date Left School

Child's Name

IRD Number

Date of Birth

Date Left School

Child's Name

IRD Number

Date of Birth

Date Left School

Child's Name

IRD Number

Date of Birth

Date Left School

If you have received Working for Families Tax Credits during the year, please supply the certificate issued to you by IRD, detailing the amounts.

Also provide details of any child support or maintenance payments made or received.

If we do not prepare your spouse or partner's taxation return, please provide us with details of their income OR attach a file below.

Spouse or Partner's income

Have there been any changes to your family circumstances, including a change in responsibility for your dependent child(ren), you have married, separated or otherwise changed your family circumstances? If so, please provide details.

Do you share custody of your child(ren) with anyone other than your partner? If so, please provide details.

Did you work on average less than 20 hours per week if single or did you and your spouse / partner combined work less than 30 hours per week? If so, please provide details.

Additional income information - Working for Families Tax Credits

From the year starting 1 April 2011 the definition of family income for Working for Families Tax Credits has been extended. You are now required to supply details of income received from the following sources:

Attributable trustee income

Attributable trustee income is all income for the year of a trust that hasn't been distributed as beneficiary income. Trustee income will be attributed only to settlors of a trust. The settlors are individuals who establish or contribute funds to the trust.