Forms starting with: A
Application for withdrawal of initial KiwiSaver contribution on the grounds of significant financial hardship or serious illness KS5
(published August 2008)
About this form
This form can be used to apply for a refund of KiwiSaver contributions held by Inland Revenue on the grounds of significant financial hardship or serious illness.
Adobe Acrobat PDF | 166kb | 6 pages
This form can be completed on-screen by typing content directly into the PDF document. Once you have completed the form it is important that you print it out as you will not be able to save the information you enter into the form.
When to use this form
Inland Revenue can only consider your situation during the first three months after receiving your first contribution. After the first three months your contributions are passed to your KiwiSaver scheme provider and you'll need to contact them directly for a refund.
If you are unsure whether to apply to Inland Revenue or your scheme provider, please call us on 0800 549 472 (0800 KIWISAVER).
What you will need
You will need to provide your name, address, IRD number and bank account.
To apply for a serious illness refund, you will need to ask your doctor to complete the doctor's declaration section of this form.
To apply for a significant financial hardship refund, you will need to provide details of your financial situation, complete a declaration of significant financial hardship and have it witnessed.
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After you finish
Please print, sign and send this completed form to the following address:
Inland Revenue
PO Box 1454
Hamilton 3240
You may wish keep a copy of this form for your personal records.
