Questionnaire Questionnaire for Tax Assessment LEARN ABOUT US Questionnaire 1 2 3 4 5 6 7 8 9 SECTION A: WORLDWIDE INCOME & GIFTSPlease complete by entering information into the applicable fields, specifying the country, and if sourced from the United States the state in the space provided.Salary, wages and employment related benefitsIncome from self-employmentRetirement fund distributionsEmployment relatedNon-employment relatedDistributions from a company (irrespective of US or NZ tax treatment)InterestDividendsRoyaltiesRental incomeEmployee share optionsBeneficiary income from a trustEstate income/inheritanceWinnings/prize moneyCapital gainsOther incomeGifts received SECTION B: WORLDWIDE INVESTMENTSPlease complete by entering information into the applicable fields, specifying the country, and if sourced from the United States the state in the space provided.Cash deposited with financial institutionsDid you have an aggregate balance of $10,000 or more in all financial account(s)If so, how many accounts did you have during the year (exclude loan accounts)?Retirement funds:Non-employment relatedShares (please specify shareholding % age)Real property:Personal residenceHoliday homeCommercial rental propertyResidential rental propertyPersonal property (for example: artwork)Other investmentsDid you dispose of any investments during the year?YesNoDid you transfer any property to a trust during the year?YesNoDid you engage in any exchange of property for other property?YesNoDid you form an entity such as a company, trust or other entity during the year?YesNoWere you the recipient or donor of any gifts during the year?YesNo SECTION C: WORLDWIDE LIABILITIESPlease complete by entering information into the applicable fields, specifying the country, and if sourced from the United States the state in the space provided.MortgagesAre mortgages secured over a principal residence?LoansOther liabilities (please specify)Did any creditor relieve you of debt or debts during the year? SECTION D: ASSOCIATIONSPlease complete by ticking in the box where applicable and entering details on line provided if prompted.Are you a settlor of a trust?YesNoPlease provide detailsAre you a director of a company?YesNoPlease provide detailsAre you a partner in a partnership?YesNoPlease provide detailsAre there are any other entities in which you have a direct or indirect financial interest?YesNoPlease provide details SECTION E: PERSONAL INFORMATIONPlease complete by entering details on line provided.Your full name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Contact phone number*Email address*Citizenships(s)SSN and/or IRD numberYour date of birth Date Format: DD slash MM slash YYYY Dependents' full name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Dependents’ citizenships(s)Dependents’ SSN and/or IRD numberAdd another dependant - 2YesNoDependents' full name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Dependents’ citizenships(s)Dependents’ SSN and/or IRD numberAdd another dependant - 3YesNoDependents' full name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Dependents’ citizenships(s)Dependents’ SSN and/or IRD numberCurrent address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 SaharaYemenZambiaZimbabwe Country Did your address change during the year?YesNoOccupationDid your occupation change during the year?YesNoMarital status (for this tax year)MarriedUnmarriedSpouse citizenships(s)Did your marital status change during the year?YesNoDid your name change during the year?YesNoAre you enrolled in the KiwiSaver Scheme?YesNoDate that you moved to New Zealand/US* Date Format: DD slash MM slash YYYY SECTION F: LOCATIONPlease complete.Did you move countries during the last 5 years?YesNo SECTION G: FILING INFORMATIONPlease complete.What was the last year you filed a US and/or NZ tax return?Can you supply a copy of the last US and/or NZ return you filed?YesNoHave you received any correspondence from IRS or IRD that you are yet to respond to?YesNo SECTION H: ENTRY/EXIT DATES FROM US AND NZCountryEntry date Date Format: DD slash MM slash YYYY Exit date Date Format: DD slash MM slash YYYY Purpose of visitAdd another journey - 2YesNoCountryEntry date Date Format: DD slash MM slash YYYY Exit date Date Format: DD slash MM slash YYYY Purpose of visitAdd another journey - 3YesNoCountryEntry date Date Format: DD slash MM slash YYYY Exit date Date Format: DD slash MM slash YYYY Purpose of visit SECTION I: MISCELLANEOUSPlease complete by entering details belowIs there any other information you wish to provide?Any special considerations for preparation?Do you require a hard copy of your return?YesNoPlease use this area to add any notes.SignatureNameThis field is for validation purposes and should be left unchanged. 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