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 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 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* 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 Exit date Purpose of visitAdd another journey - 2YesNoCountryEntry date Exit date Purpose of visitAdd another journey - 3YesNoCountryEntry date Exit date 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.SignaturePhoneThis field is for validation purposes and should be left unchanged. 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