EmailMe Form - INDIVIDUAL QUESTIONNAIRE

Name *

First Last

Email *

PERSONAL INFORMATION FOR TAX RETURNS

COVERING FULL FINANCIAL YEAR ENDED: *

1. Income with tax deducted.

Did you receive any income from which tax was deducted?
Salary or Wages
Income Tested Benefits
Accident Compensation
National Superannuation
Other Pension/Superannuation Schemes

YES

NO

The IRD Summary of Earnings will be sent directly to us.

2. Interest received.
Did you receive any interest during the year?
(Please provide Certificates as they include details for the whole year.)

YES

NO

Source of Interest

3. Dividends received.
Did you receive any dividens during the year?
(Please provide certificates, including those for shares in lieu of dividends.)

YES

NO

Source of dividends

4. Overseas Income.
Did you receive any overseas income during year?
(Please supply details of any such income.)

YES

NO

Examples below of income and information required. Overseas interest, dividends, wages received, and taxation paid Any overseas investments held during the year and all reports
relating to them Interest in a foreign company, unit trust, life insurance policy or superannuation schemes.

Source of overseas income

5. Other Income or Loss.
Did you receive any other income or loss during the year?

YES

NO

If from a partnership, trust, look-through company or an estate, please supply the following details:

Name of Entity

IRD No:

Share of Profit / Loss

Please supply details of any other income

6. Charitable Donations.

We will complete and file these returns if required. Please indicate if you have already filed your own rebate claim return.

Do you require us to complete your rebate claim return?

Yes

No

If Yes – please provide details of your donations (receipts).

7. Expenses

Attach details of expenses incurred in earning income (other than your PAYE/employment income) Examples are income protection insurance, commissions, interest on loans used to buy investments.

Details of expenses

Upload expense documents

8. Working for Families Tax Credits (WFFTC)

Did you receive WFFTC or are entitled to it as an end of year adjustment?

Yes

No

If yes, please supply the following details:

Names of children and date of birth.

(Please supply full details of any children born during the year,
and those who left school during the year.)

If you answer Yes to ANY of the questions below– please provide details on a separate sheet.

Other Income for WFFTC:

Attributable trustee income of trusts where you are the Settlor.

Yes

No

Attributable fringe benefits.

Yes

No

PIE income.

Yes

No

Passive income from children if over $500 per year per child.

Yes

No

Income from non-resident spouse.

Yes

No

Tax exempt salary & wages.

Yes

No

Pensions & Annuities.

Yes

No

Income Equalisation Scheme Deposits.

Yes

No

Royalties.

Yes

No

Income held in closely held companies.

Yes

No

Maori Authority.

Yes

No

Other payments received over $5,000 per year used for day to day expenses.

Yes

No

9. Do you know of anything that may cause the coming year’s provisional tax to be significantly different to the current year?

Yes

No

If "Yes", please explain.

10. REFUND BANK ACCOUNT

Please provide the bank account name and number that should there be a refund you would like it to be deposited into.

Bank Account name

Bank Account number

11. General:
Is there anything else you consider relevant?

12. Address confirmation:
Please confirm your current postal address below.

13. Meeting:
Once your financial statements and/or tax returns are complete, do you wish to have a meeting to discuss them?

Yes

No

14. Instructions / Authorisation for BTA Ltd:

I instruct BTA Ltd to prepare my taxation return. I undertake to supply all information necessary for this engagement and to be responsible for the accuracy and completeness of such information. Your services are not intended to and accordingly will not result in the expression by you of an opinion on the tax return summary or related schedules insofar as third parties are concerned.

Authorisation to obtain information subject to the Privacy Act:
I authorise BTA Ltd to communicate with the appropriate bankers, solicitors, finance companies and other persons or organisations to obtain such further information as is required to carry out the above engagement.

Signature - Draw your signature/initials using a mouse, or your finger/stylus on a touchscreen.

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Date *

DD / MM / YYYY