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About this form

If you are a hospital patient or prison inmate and you want an exemption from paying child support or spousal maintenance you can use this form.

Adobe Acrobat PDF | 59kb | 2 pages

When to use this form

Use this form if you are in hospital or in prison for 13 weeks or more and you want to apply for an exemption from paying child support or spousal maintenance.

What you will need

• Your IRD number
• this form to be completed by an authorise officer of the hospital or prison
• offical stamp from the hospital or prison

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After you finish

Please print, sign and have the completed form signed and stamped by an authorising officer and send to your nearest Inland Revenue office.
You may wish to keep a copy for your personal records.

List of postal addresses for Inland Revenue >