•   by keyword  
•   by title  
•   by number  

About this form

This form is for self-employed persons applying for paid parental leave. This form also provides information on what paid parental leave is, who is eligible and how to apply.

Adobe Acrobat PDF | 215kb | 8 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

Fill in this form to apply for paid parental leave as a self-employed person after you have confirmed by carefully reading the introduction and the notes in the form that you qualify for paid parental leave.

You can apply for paid parental leave before your parental leave commences, or at any time while you're on leave. You must, however, apply for the payments before you return to work or resign.

Most of the information on this form can be completed on-screen by typing content directly into the PDF document. Your statement and/or self-declaration you need to fill in by hand and some information from your chartered accountant or a Justice of the Peace must also be filled in by hand, including signatures. 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.

What you will need

• Your IRD number - if you do not have this call us on 0800 227 774.
• Birth date or expected due date of your child or the date you assume care of a child you intend to adopt
• Your bank account number

This form has two sections that must be filled in. You (the applicant) need to fill in the applicant's section, and then have your chartered accountant complete their contact information and confirm your information in the "Chartered accountant's statement". If you don't have a chartered accountant, you must make a self-declaration witnessed by a Justice of the Peace, solicitor or other person authorised to take a statutory declaration.

Download Acrobat Reader to view PDF files

Report an accessibility problem for this page

After you finish

When all relevant sections of the form have been completed, send it to us at the following address:

Inland Revenue
PO Box 3752
Christchurch.

List of postal addresses for Inland Revenue >