Questionnaire for Tax Assessment 1 2 3 4 1. CONTACT INFORMATIONMarital Status*SingleHead of HouseholdMarried Filing SeparatelyMarried Filing JointlyQualifying Widow/Widower with Dependent Child FilingI’m not sureTaxpayerTitle*First Name(s)*Last Name*Email* Mobile Phone*Daytime PhoneCurrent Address*City*State / ProvinceZIP / Post Code*Country*AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweAre you a US Citizen?*YesNoWhat other Citizenship's do you hold?Do you or have you at any point held a US Green Card*YesNoDate Issued Date Format: MM slash DD slash YYYY Date Rescinded Date Format: DD slash MM slash YYYY SpouseTitleFirst Name(s)Last NameEmail Mobile PhoneDaytime PhoneAre you a US Citizen?YesNoWhat other Citizenships do you hold?Do you or have you ever held a US Green Card?YesNoDate Issued Date Format: MM slash DD slash YYYY Date Rescinded Date Format: DD slash MM slash YYYY 2. TAX SERVICESWhat taxation services are you looking for?USNZBothDo you need to file a US tax return for the current tax year?YesNoFor which tax year did you last file a US tax return?Can you supply a copy of the last US return you filed?YesNoHave you received any correspondence from the IRS that you are yet to respond to?YesNoFor which tax year did you last file a NZ tax return?Can you supply a copy of the last NZ return you filed?YesNoDo you need to be reminded of provisional and terminal tax payments (if any)?*YesNoHave you received any correspondence from the IRD that you are yet to respond to?YesNo 3. QUESTIONSDid you or your spouse live in the USA during the US tax year?*YesNoWhich state?*Do you receive salary, wages and employment related benefits?Yes - from the USYes - from NZYes - from another countryNoUS State where earned*Country where earned*Are you self-employed or do you receive hobby income?Yes - from the USYes - from NZYes - From another countryNoUS State where earned*Country where earned*Did you dispose of any investments during the year?YesNoWere you the recipient or donor of any gifts during the year?YesNoDo you have an investment portfolio outside the US?YesNoFor the following, please select the country from which you received them.Interest US NZ Other US State where earned*Country where earned*Dividends US NZ Other US State where earned*Country where earned*Distributions from Trusts US NZ Other US State where earned*Country where earned*Distributions from a company US NZ Other US State where earned*Country where earned*Employee Share Options US NZ Other US State where earned*Country where earned*Estate Income / Inheritance US NZ Other US State where earned*Country where earned*Capital Gains US NZ Other US State where earned*Country where earned*Royalties US NZ Other US State where earned*Country where earned*Rental Income US NZ Other US State where earned*Country where earned*Distributions from Partnerships US NZ Other US State where earned*Country where earned*Distributions from S-Corporations US NZ Other US State where earned*Country where earned*Income from farming US NZ Other US State where earned*Country where earned*Gifts ($15,000 USD) US NZ Other US State where earned*Country where earned*Employment related retirement fund distributions US NZ Other US State where earned*Country where earned*Have you deposited more than $10,000 USD cash with financial institutions?YesNoCountry / State for deposited cash*Have you, at any point in the calendar year, had a total balance (from all non-US accounts) that is greater than or equal to $10,000 USD?YesNoHow many accounts did you have? (exclude loan accounts)*Do you prepare your own FBARs? (FinCEN 114)YesNoDo you require your financial statements to be compiled?*YesNoPlease select the following options that apply to you Trustee of a trust Settlor of a trust Partner in a partnership Beneficiary of a trust Directory of a company Shareholder of a company Percentage of Shareholding Less than 10% 10% - 50% 51% - 100% Please provide entity names.* KiwiSaverDo you have a KiwiSaver or similar account for yourself, partner or any dependents?YesNoDo you make voluntary/additional contributions (outside of your employment contributions) to KiwiSaver accounts for you, your partner or dependents?YesNo 4. ADDITIONAL INFORMATIONIs there any other information you wish to provide?Any special considerations for preparation?How did you hear about us?*Declaration:I hereby declare that the details provided above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.SignatureDate Date Format: DD slash MM slash YYYY NameThis field is for validation purposes and should be left unchanged. Call us to make an appointment today. +64 9 525 5931 CONTACT US
