Online Application

First Name:

Last Name:

IRD Number:

Street Address:

Town or City

Post Code

Email address:

Contact Phone Number:

Date of Birth:

(DD/MM/YYYY)

Did you receive any New Zealand interest? Yes No Help ?

Did you receive any New Zealand dividends? Yes No Help ?

Tax Year

Dividend Received From

Gross Dividend

Imputation Credit

RWT

Did you receive any other income? Yes No Help ?

Can you claim any expenses against your income? Yes No Help ?

Did you make any donations or pay for childcare? Yes No Help ?

Please note that you may only apply for a rebate if you have earned taxable income &:

For Donations:		For Childcare/Housekeeper payments:
Have donated $5 or more to:		-Have paid for childcare as a working parent
-An approved charitable organisation		-Have paid for a housekeeper, where you
-An approved New Zealand religious organisation		(or your partner) were disabled or physically unable
-An approved overseas aid fund		to do the housework.
-Free Kindergarten Associations
-State schools, school boards of trustees or parent teacher associations

Please enter your Bank Account Details:

Bank Account Number

Donation:

Tax Year

Donation made to

Amount Paid

Childcare/Housekeeper Payment:

Tax Year

Payment made to

Amount Paid

Under 19 and still at school(in the last 5 years)? Yes No Help ?

Do you owe any Child Support arrears? Yes No Help ?

Client Declaration

I certify that I am the above named person and the IRD number I have supplied is my own.

I authorise Refund Me Limited to be my tax agent and to act on my behalf with the Inland Revenue Department, including the requesting and confirmation of my Personal Tax Summary(s), the completion and filing of my IR526 (Rebate claim form/s) and cancelling old bank accounts with Inland Revenue (if necessary).

I confirm that I have supplied Refund Me Limited with details of all my taxable income and deductible expenditure.

I confirm that I am a New Zealand Tax Resident.

I confirm that I do not owe any Child Support arrears to the Inland Revenue Department.

I agree to the fee structure as detailed below and I authorise Refund Me Limited to deduct this fee from my tax refund or rebate claim.

I authorise Refund Me Ltd to have any tax refunds paid directly to the Refund Me Ltd Trust account by Inland Revenue. Refund Me Limited will then forward the balance to my bank account or by cheque after deducting the commission charged.

Tax Refund/Rebate	Commission Charged
Less than $50	No Charge
$50 - $150	$30
$151 - $200	$50
$201 - $300	$70
$301 - $500	$120
$501 - $750	$150
$751 - $1500	$200
More than $1500	$350

Disclaimer of Liability

We have not performed an audit or review of the information provided, neither we nor any of our employees accept any responsibility for the accuracy of the material from which the return has been prepared. Further, the return has been prepared at the request of and for the purpose of the client only, and neither we nor any of our employees accept any responsibility on any grounds whatever, including liability in negligence, to any other person.

I confirm that I have read and accept the above Client Declaration and Disclaimer of liability? Yes, I agree.

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