Personal Income Questionnaire (118 KB)

(Click above to download a hardcopy of our questionnaire or complete online below)

Name:*
Postal Address:*
Street Address:
Home Address:
Contact Name 1:*
Contact Name 2:
Email:*
Income Tax Year:*	Please Select 2011 2010 2009 2008 2007 2006 2005 2004 junk

Please tick the box beside the item if you intend forwarding that item at a later date

1	Income: Please provide the following
a	Certificate of Earnings:
	PKF Goldsmith Fox will obtain this from the IRD directly.
b	Interest and Dividends:
	An Interest Withholding Tax Deduction Certificate (IR15) will be sent to you by tour bank, or other financial institutions, indicating the amount of tax deducted from interest earned. We require these for joint accounts also. A dividend payment advice will accompany dividend cheques indicating withholding tax deductions or imputations credits. Income from Portfolio Investment Entities (PIE)
c	Other Income and Expenses:
	Rents Received (Gross Rents and Expenses)
	Income from Partnerships/Trusts/Estates (not prepared by us)
	Overseas Investments - details of all foreign investments and income
	Expenses to obtain self-employed income e.g. real estate agents
	Any other income
2	Rebates - These reduce your tax liability
a	Low Income (less than $9,880):
	Did you work more than 20 hours per week?  Yes  No
	If so, for how many weeks?
b	Donations
	Attach all receipts for donations to schools, churches, charitable organisations. Minimum donation is $5
c	Housekeeper/Childcare
	Name of Housekeeper/Childcare provider Receipts Total                                                        $
d	Family Assistance:
	You may be entitled to this rebate which is dependent on joint family income and number of children:
	Attach names of children, birth dates and IRD number(s)
	Attach details of changes in your family circumstances during the year
	Did you and your spouse work more than 30 hours per week between you during the year?  Yes  No If so, for how many weeks of the year?
3	Student Loans
	Do you have a student loan?  Yes  No
	If "Yes", supply details.
4	Child Support
	Did you receive/pay Child Support during the year?  Yes  No
	If "Yes" supply details.
5	Income Protection Insurance
	Please provide details.
	*Have you filled out a "Terms of engagement form"?  Yes  No
	On completion of this form you will be emailed a copy of the information for your records. This Email will contain the link to the "Terms of Engagement form" You are required to either fax or mail this back to Goldsmith Fox as soon as possible.
	For the attention of :   junk Please Select Roger Keys Ron Bruce Dennis Lay Brian Lennox Gordon Hansen John Purvis Carol Fletcher Robin Wah Trevor Bayliss Dorian Crighton