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Application for withdrawal of initial KiwiSaver contribution on the grounds of significant financial hardship or serious illness (KS5)

(published May 2011)

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.

PDF | 186kb | 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 to discuss your eligibility for a  refund.

If you are unsure whether to apply to Inland Revenue or your scheme provider, please contact us.

Do not use this form outside your first three months of membership. After this period you need to contact your KiwiSaver scheme provider.

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.

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 >