Financial Statements Questionnaire for Individual

Please ensure that all records as requested throughout this questionnaire, are included.

If you are unable to provide certain information, please include your notes about this in the field provided below each question.
We look forward to seeing you in the office when you bring them in.

Client Name:*

Balance Date:*

Please indicate which financial year end the data in this questionnaire relates to

Phone:*

Mobile:*

Email:*

Terms of Engagement

To Raynes Gibson & Matthews Accountants Ltd
I/We hereby instruct you to prepare my/our Financial Statements and Taxation Returns for this year from the information and records I/We have supplied to you.
I/We accept responsibility for the accuracy and completeness of all records and information supplied to you.
You are hereby authorised to communicate with my/our bankers, solicitors, finance companies, and any other business that I/We deal with to obtain such information as you require in order to complete the above duties.

Signature*

Date*

A convenient time to call you is:

Alternative phone numbers:

When do you want your accounts completed by?

Wages / National Superannuation / Benefits

Please list the names of any organisations you have received the following from:

(In most cases we will obtain these records directly from the IRD however, we do need to check all details have been included).

Wages	ACC Payments	National Superannuation	Any other benefits

Kiwisaver

Do you have a Kiwisaver?

Yes
No

What is your Prescribed Investor Rate (PIR)?

0%
10.5%
17.5%
28%

Student Loan

Do you have a Student Loan?

Yes
No

Please provide your latest statement from the IRD, or leave us a note in the field below.

Drop files here or

Max. file size: 128 MB.

I am unable to supply the above information at this time because

(please send us a note as to why this information cannot be supplied at this time).

Goods & Services Tax (GST) Returns

Have your GST Returns been prepared by us?

Yes
No

Please provide copies of your Goods & Services Tax (GST) Returns and work papers, or leave us a note in the field below

Drop files here or

Max. file size: 128 MB.

I am unable to supply the above information at this time because

(please send us a note as to why this information cannot be supplied at this time).

Interest & Dividends

Have you received any Interest or Dividends?

Yes
No

Please supply the Interest and/or Dividend statements

- For interest received, you should have an annual advice notice showing the withholding tax deducted. If not please provide a Resident Withholding Certificate for Interest earned from your bank(s)
- Please provide details of any dividends received and if any dividends are taken as bonus shares, also include these advice slips
- Or, leave us a note in the field below

Drop files here or

Max. file size: 128 MB.

I am unable to supply the above information at this time because

(please send us a note as to why this information cannot be supplied at this time).

Rental & Leased Property

Do you own property that is Rented or Leased?

Yes
No

Please ensure you complete our Rental questionnaire, or send us a note below

Self Employed Income

Do you earn income from Self Employment?

Yes
No

Please ensure you complete our Business questionnaire, or send us a note below

Partnerships, Trusts, Estates and Companies

Do you have a Partnership, Trust, Estate or Company?

Yes
No

Please ensure you complete our Business or Trusts questionnaire, or send us a note below

I am unable to supply the above information at this time because

(please send us a note as to why this information cannot be supplied at this time).

Overseas

Did you receive any overseas income?

Include overseas interest, dividends, wages received and taxation paid.
Note: New Zealand tax residents are liable for tax on world-wide income

Yes
No

Please provide the following details, or leave us a note in the file below.

- Please provide details of the value and quantity of the investments held at any time during the financial year.
- Please provide the date, value and details or any purchase, sales and income (dividends)
- Please attached all of your investments advisor's reports. This information is required so we can calculate if any income needs to be declared under the FIF (Foreign Investment Fund) rules.

Drop files here or

Max. file size: 128 MB.

I am unable to supply the above information at this time because

(please send us a note as to why this information cannot be supplied at this time).

Any Other Income

Please upload details

- Income Replacement Insurance Policy - provide details of premiums and claims as these may be deductible
- Look Through Company - if you have been allocated a share of a loss other than from a company that we are aware of, please provide details
- Or leave us a note in the field below

Drop files here or

Max. file size: 128 MB.

I am unable to supply the above information at this time because

(please send us a note as to why this information cannot be supplied at this time).

Donations, (Note from 2013: Housekeeping and Childcare Tax Credits are no longer claimable)

Would you like us to complete your rebate claim form?

Please note: If yes, you will need to bring the ORIGINAL donation receipts in to our offices

Yes
No

Working for Families Tax Credits and Parental Tax Credits

The IRD will calculate this for you.

Please supply full names and birth dates of all children. Please note the following

- If you had a child born within the current financial year you may be eligible for the Parental Tax Credit.
Please include their IRD Number below.
If you do not have this, you will need to obtain one for them in order to claim any entitlement for them.
- Where a child has become financially independent during the current financial year, please advise the date they left school or home.

Child's Name	IRD No.	Date of Birth	Date Left School

Please provide the following:

- If you have received Working for Families Tax credits during, please supply the certificate issued to you by the IRD, detailing the amounts
- Also provide details of any child support or maintenance payments made or received.
- Or send us a note in the field below

Drop files here or

Max. file size: 128 MB.

I am unable to supply the above information at this time because

(please send us a note as to why this information cannot be supplied at this time).

Thank you for completing this questionnaire.

Your time and effort is appreciated.
**Please ensure you have provided all the information required to complete your Financials & Tax Returns.
Lack of complete information may mean an increase in fees as we need to follow up for more information.

Please select the staff member you would like to email your questionnaire to*

Raynes Gibson & Matthews Accountants Ltd - Financial Statements Questionnaire for Individuals

Please ensure that all records as requested throughout this questionnaire, are included.

Terms of Engagement

Wages / National Superannuation / Benefits

Kiwisaver

Student Loan

Goods & Services Tax (GST) Returns

Interest & Dividends

Rental & Leased Property

Self Employed Income

Partnerships, Trusts, Estates and Companies

Overseas

Any Other Income

Donations, (Note from 2013: Housekeeping and Childcare Tax Credits are no longer claimable)

Working for Families Tax Credits and Parental Tax Credits

Thank you for completing this questionnaire.

Raynes Gibson & Matthews Accountants Ltd

Raynes Gibson & Matthews
Accountants Ltd