Download - Inland Revenue Department

IR 109 (14)
September 2012
Estimate of income for child support assessment
– for paying parents living in Australia 2014
1 April 2013 to 31 March 2014 (New Zealand child support year)
Use this form if you want to estimate your current taxable income for your child support assessment for 2014.
Please answer every question. If you need help to complete this form please call us on 1 800 504 042.
Another estimate of taxable income can be made before or during the child support year, but not after, by completing another
copy of this form, or by applying to us in writing.
For details on estimations and penalties please see our factsheet Estimating your income (IR 151).
The income you estimate must be at least 15% lower than the income used to work out your current child support assessment.
Child support forms and other information are available on our website www.ird.govt.nz/childsupport/
Paying parent to complete
1. Your New Zealand IRD number
(8 digit numbers start in the second box. )
2. Your name (Tick one) Mr Mrs Miss Ms
Surname
First names
3. Your date of birth
Day Month Year
4. Your home address
Street address
Town or city
5. If your postal address for child support
is different from your home address,
print it here
Street address or PO Box number
Town or city
6. Your contact details Phone 0061 ( ) 0061 ( )
Daytime
Evening
0061 ( )
Fax
Email
7a. Do you have any
New Zealand income
Please attach evidence to verify
income, for example, a letter or
payslip from Work and Income,
your employer or accountant
No
Yes – please show the details below
Actual New Zealand taxable income
earned since 1 April 2013
Expected New Zealand taxable income to
be earned up to 31 March 2014
Total New Zealand income

7b. Do you have any Australian income
Please attach evidence to verify
income, for example, a letter or
payslip from Centrelink, your
employer or accountant
No
Yes – please show the details below
Actual Australian taxable income earned
since 1 July 2013
Expected Australian taxable income to be
earned up to 30 June 2014
Total Australian income
Declaration
I choose to use this estimate of my taxable income as my child support
income amount, for the child support year 2014. I understand that if my
expected income changes I must re-estimate my income before 31 March 2014.
To the best of my knowledge the information I have given is true and correct.
Checklist
Have you:
answered every question
signed and dated this form
given details of your income
read and understood the factsheet Estimating your income (IR 151)
Please send this completed form to:
Child Support
PO Box 39010
Wellington Mail Centre
Lower Hutt 5045
For more information about Child Support go to www.ird.govt.nz/childsupport/ or call us on 1 800 504 042.
Privacy
Meeting your child support obligations involves giving accurate information to Inland Revenue. We ask you for information so we
can assess your liabilities and entitlements under the Child Support Act 1991.
We may also exchange information about you with:
• some government agencies
• another country, if we have an information supply agreement with them
• Statistics New Zealand (for statistical purposes only).
If you ask to see the personal information we hold about you, we’ll show you and correct any errors, unless we have a lawful reason
not to. Call us on 0800 377 774 for more information. For full details of our privacy policy go to www.ird.govt.nz (keyword: privacy).
OFFICE USE ONLY
Total Australian income from Box B
Exchange rate
Income in New Zealand
Plus total New Zealand income from Box A
Total estimated income