Documents numbered between 001 and 99
Statement of financial position IR40
(published April 2011)
About this form
Complete this form if you're a salary or wage earner or a beneficiary, and you're having or expecting to have difficulties in meeting your repayment responsibility. For example, if you're planning on travelling overseas.
Adobe Acrobat PDF | 161kb | 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're having a problem (or expecting to have a problem) 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'll need to provide us with details of your assets and liabilities.
You'll also need to supply us with a proposed amount you would like to pay, how often you would make this payment, and how you'll 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.