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About this form

Complete a certificate for the year ending 31 March for each shareholder you paid specified dividends / Maori authority distributions to.

Adobe Acrobat PDF | 125kb | 2 pages

When to use this form

Use this form for paying resident withholding tax (RWT) deducted:

• from "specified dividends" which are one of the following:
  • dividends paid by companies which:
    • at the time are not resident in New Zealand, or
    • are prohibited by their constitution from distributing all income to any proprietor, member or shareholder, or
    • whose incomes are exempt; or who are solely engaged in life insurance or re-insurance
  • dividends paid on specified preference shares
  • amounts distributed by a Maori authority that are treated as dividends

Note that these dividends have no imputation or dividend withholding payment credits to attach.

• by agents or trustees from dividends received on behalf of another person.

What you will need

• IRD number
• month and year specified dividend was paid
• gross dividends
• imputations credits
• dividend withholding payments.

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After you finish

Please print, fill in all the details, 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 >