Rebate Claim Form
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1
2IR 526
September 2007
Your name
IRD number
1
YEAR ENDING
Your address
Tax year
2
31 March
Your daytime telephone
REBATE CLAIM FORM
Donations, childcare or housekeeper payments
TOTAL AMOUNT YOU PAID
Enter the total amount you paid in donations to approved charities in
3
Box 3 and staple your donation receipts to the back of this form.
(Box 3 from worksheet)
Enter the total amount you paid for childcare or a housekeeper in
TOTAL AMOUNT YOU PAID
Box 4 and staple your childcare or housekeeper receipts to the
4
(Box 4 from worksheet)
back of this form. Print the name of your childcare provider or
NAME OF CHILDCARE PROVIDER OR HOUSEKEEPER
housekeeper here. If there is more than one childcare provider or
housekeeper attach a list of their names to this form.
If your income before tax was less than $2,900 tick this box.
5
If there is no bank account number shown below, or you would
BANK
BRANCH
ACCOUNT NUMBER
SUFFIX
like us to deposit your rebate to a different number, please enter
6
this number in the space provided.
If your suffix has only two numbers, enter them in the first two squares of the
suffix box.
If you have a building society account, please read the note on the worksheet
(IR 527).
If you want to transfer your rebate to your or someone else’s
IRD NUMBER
income tax account, read the notes on the worksheet (IR 527) and
7
enter the details in the boxes.
(8 digit numbers start in the second box.
)
AMOUNT TO TRANSFER
TRANSFER TO YEAR ENDING
Name of person receiving rebate
8
31 March
Please sign and date the declaration below.
SIGNATURE
DATE
I declare that the information I have provided on this form is
/
/
true and correct.
We will send you confirmation of the
amount of your rebate in six weeks
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