Application for an administrative review - Inland Revenue Department

Application for an administrative review
IR 470
March 2012
These details and any supporting information may be passed on to the other party.
Please fill in both sides of this form.
Your name Mr Mrs Miss Ms
(To help us, show the name
you use for child support)
Surname
First name(s)
Request for review
I believe there are special circumstances that are not taken into account by the formula assessment.
I am applying under section 96B of the Child Support Act 1991 for an administrative review of the assessment for these years.
year ending 31 March year ending 31 March year ending 31 March
Grounds for applying
The grounds for my application are number(s) (see pages 15–22 of our booklet
Helping you to understand child support reviews (IR 175) and print the numbers in the boxes)
The special circumstances are: (Describe how your situation matches the grounds indicated)
OFFICE USE ONLY
Child Support www.ird.govt.nz/childsupport/ 0800 221 221

Your IRD number (8 digit numbers start in the second box. )
Postal address
Street address
Town or city
Postcode
Telephone number ( ) ( ) ( )
Day Evening Mobile
Hearing requirements (tick as appropriate)
Will you be present at the hearing? Yes No
If “no”, would you prefer your part of the hearing to be done by phone or on the
information you have provided in writing?
Do you want to bring a support person to the hearing?
Please attach support person’s details.
Do you want to have a representative attend the hearing?
(See page 24 of our booklet Helping you to understand child support reviews (IR 175))
Previous applications
Phone
Have you previously applied for a review? Yes No
Have you previously applied for a departure order or an appeal through the Family
Court?
Declaration
To the best of my knowledge the information I have provided is true and correct.
Yes
Yes
Yes
Writing
No
No
No
Information about the other party
Name of other party Mr Mrs Miss Ms
Surname
First name(s)
Postal address
Street address
Town or city
Postcode
Telephone number ( ) ( ) ( )
Day Evening Mobile
Privacy
Meeting your child support obligations involves giving accurate information to Inland Revenue. We ask you for information so we
can assess your liabilities and entitlements under the Child Support Act 1991.
We may exchange information about you with Work and Income, the Ministry of Justice, the Ministry of Education, New Zealand
Customs Service, Accident Compensation Corporation, or their contracted agencies. Information may also be provided to
overseas countries with which New Zealand has an information supply agreement. Inland Revenue also has an agreement to
supply information to Statistics New Zealand for statistical purposes only.
You may ask to see the personal information we hold about you by calling us on 0800 221 221. Unless we have a lawful reason
for withholding the information, we will show it to you and correct any errors.

IR 178
June 2010
Child support administrative review – statement of
financial position
Important!
• Completing this form is optional. Information you provide below may be passed on to the other party to the review. Although
it’s not mandatory to provide this information, it will help the Review Officer to consider all the circumstances of your case and
determine how any change to the child support assessment would affect each party.
• Please carefully fill in as many details as you can. If you need more space, use an extra sheet of paper—write your name and
IRD number on it.
• If you need any help with completing this form, please phone us on 0800 371 333.
• Child Support forms and other information are available on our website at www.ird.govt.nz/childsupport/
Your details
Your IRD number (8 digit numbers start in the second box )
Your name
Surname
First names
Your address
Street address
Town or city
Postcode
Phone number(s) ( ) ( ) ( )
Day Evening Mobile
Name and address of employer
Name
Address
Phone number(s) ( ) ( ) ( )
Day Evening Mobile
Your occupation or job
(If you have more than one employer, show the one you work the most hours for)
Declaration
To the best of my knowledge the information I have provided is true and correct.
I understand that all information will be provided to the other party for the purpose of this review.
Notes
• If you have any other comments, or any other information you think will help us understand your situation, please write the details
on a separate sheet of paper and attach it to this form. Make sure you write your name and IRD number on the paper.
• We may ask you to provide proof of details shown on this form (such as payslips or invoices).
• There are penalties for deliberately giving false or misleading information.
OFFICE USE ONLY Review case number Applicant Other party Office

Income
Please show your income details before tax and other deductions such as superannuation, union fees or insurance are taken out.
Only give details about personal income and expenses, not company, partnership or trust details.
Salary or wages from regular job(s)
Work and Income
Type__ __ __ __ __ __ _
benefit
Type__ __ __ __ __ __ _
ACC payments
Pay for temporary, casual or part-time work
Drawings from business
Self-employed income
Superannuation
Working for Families Tax Credits
Child support or maintenance
Rent or board
Interest or dividends
Other
_ __ __ __ __ __ __ __ _
Your yearly income Your monthly income Income of spouse or
partner living with you
Please give information about
every person you financially
support or help support.
Name
Relationship to you (for example,
son, mother, partner)
Date of birth
(children only)
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
Include anyone you support
who doesn’t live in the same
house as you.
/ /
/ /
/ /
/ /
/ /
/ /
/ /

Expenses
How much do you pay each month for the following? Your monthly share Spouse or partner’s share
Rent, board or mortgage
House maintenance
House and contents insurance
Rates
Power and gas
Telephone, including mobile
Food and groceries
Cigarettes and alcohol
Entertainment
Rental of household items
TV rental, including Sky
Hire purchase (payments only—show details of what you owe on the
next page)
Bus, train, taxi fares and petrol
Vehicle registration and insurance
Vehicle maintenance
Clothing and footwear
Childcare
School expenses
Child support or maintenance payments
Access to children (travel and accommodation)
Animal expenses (food, vet, registration)
Work and Income repayments
Medical (not claimed on insurance)—doctor, dentist, pharmacy, optician
Insurance (medical, life, other)
Superannuation contributions
Store cards, such as Farmers, or The Warehouse (payments only—
show details of what you owe on the next page)
Credit card repayments (payments only—show details of what you
owe on the next page)
Bank or loan repayments (payments only—show details of what you
owe on the next page)
Donations
Tax
Total monthly expenses
OFFICE USE ONLY Total income Total assets
Total expenses
Balance
Total liabilities
Balance

Assets and liabilities
What you own and what you owe
House Ownership Value Amount owing
self joint
Term of loan Date started / /
Other real estate (give details, for example, flats, land)
Term of loan Date started / /
Term of loan Date started / /
Motor vehicles
Make and year
Term of loan Date started / /
Make and year
Term of loan Date started / /
Furniture and household items
Personal items (for example, jewellery)
Other loans or purchase agreements
Purpose
Term of loan Date started / /
Purpose
Term of loan Date started / /
Credit cards or store accounts
Other—include any money owed to you (give details)
Savings and investment accounts
Shares, debentures, bonds, life insurance
Have you signed and dated the declaration on the front page?
Total