PO Box 6490 Upper Riccarton Christchurch 03 348 1661
[email protected]
Working for Families Details Section 1 – Your Details First Name: _______________________
Last Name:___________________________
DOB: ______/________/_____________
IRD#:________________________________
Phone Number: ____________________
Email:_______________________________
Section 2 – Your Child/Children’s Details Full Name: ___________________________________ DOB: ______/________/_____________ IRD#:________________________________ Do you have shared custody:
☐Yes ☐No
If Yes how many days a fortnight is this child in your care:___________________ Date child came into your care: ______/______/_________ And/Or Date child left your care: ______/______/_________ Do you receive private maintenance for this child: ☐Yes
☐No
If Yes, How much per week:___________________ Full Name: ___________________________________ DOB: ______/________/_____________ IRD#:________________________________ Do you have shared custody:
☐Yes ☐No
If Yes how many days a fortnight is this child in your care:___________________ Date child came into your care: ______/______/_________ And/Or Date child left your care: ______/______/_________ Do you receive private maintenance for this child: ☐Yes
☐No
If Yes, How much per week:___________________ Full Name: ___________________________________ DOB: ______/________/_____________ IRD#:________________________________ Do you have shared custody:
☐Yes ☐No
If Yes how many days a fortnight is this child in your care:___________________ Date child came into your care: ______/______/_________ And/Or Date child left your care: ______/______/_________ Do you receive private maintenance for this child: ☐Yes
☐No
If Yes, How much per week:___________________ Full Name: ___________________________________ DOB: ______/________/_____________ IRD#:________________________________ Do you have shared custody:
☐Yes ☐No
If Yes how many days a fortnight is this child in your care:___________________ Date child came into your care: ______/______/_________ And/Or Date child left your care: ______/______/_________ Do you receive private maintenance for this child: ☐Yes If Yes, How much per week:___________________
☐No
Full Name: ___________________________________ DOB: ______/________/_____________ IRD#:________________________________ Do you have shared custody:
☐Yes ☐No
If Yes how many days a fortnight is this child in your care:___________________ Date child came into your care: ______/______/_________ And/Or Date child left your care: ______/______/_________ Do you receive private maintenance for this child: ☐Yes
☐No
If Yes, How much per week:___________________ Full Name: ___________________________________ DOB: ______/________/_____________ IRD#:________________________________ Do you have shared custody:
☐Yes ☐No
If Yes how many days a fortnight is this child in your care:___________________ Date child came into your care: ______/______/_________ And/Or Date child left your care: ______/______/_________ Do you receive private maintenance for this child: ☐Yes
☐No
If Yes, How much per week:___________________
Section 3 – Your Partner’s Details Do you have a partner: ☐Yes
☐No
If you answered Yes is your hours work more than 30 hours combined: ☐Yes If you answered No is your hours work more than 20 hours: ☐Yes
☐No
☐No
Partners full name: _________________________________ Period living together: _______________________________ Partners IRD#: ____________________________________ Is your partner a client of My Refund Limited: ☐Yes
☐No
If your partner is not a client of My Refund Limited, you can simply have them complete an online application to speed up the processing of your return and help with squaring up your Working for Families.
Section 4 – Agreement I give permission for My Refund Limited to square up my Working for Families payments for the current tax returns outstanding ☐Yes
☐No
I also give permission for My Refund Limited to continue squaring up my Working for Families any future returns necessary ☐Yes
☐No
Signature: _______________________________
Date:_______/__________/____________
Office Use ONLY Date Received:______/_______/________ Signature: ________________________________
Information Entered By: ______________________
