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About this form

Complete this form if you are having or expecting to have difficulties in meeting your repayment responsibility (for example, if you're planning on travelling overseas).

Adobe Acrobat PDF | 295kb | 4 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

If you are having problem (or expecting to) with making a payment you would use this form to advise us of your assets and liabilities so that we can negotiate your payments with you.

What you will need

You will need to provide us with details of you assets and liabilities.

You will also need to supply us with a proposed amount you would like to pay, how often you would make this payment and how you will make the payments.

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After you finish

Please print, sign and post the completed form to your nearest Inland Revenue office.

You may wish keep a copy of this form for your personal records.

List of postal addresses for Inland Revenue >