Fillable Form Ir880 - Paid Parental Leave (Ppl) Application (Page 7 of 8) in pdf

Statutory declaration

Only complete this section in front of a Justice of the peace or other person authorised to take a statutory declaration

[name]

[address, occupation], solemnly and sincerely declare that:

1 For statement 1 and 2 delete (a) or (b) which ever does not apply.

(a) I was/am* employed as an employee

*delete whichever does not apply.

(b) I was/am* self-employed because I was/am working, other than as an employee, doing 1 or more of the following:

(i) providing goods or services for hire or reward under a contract for services:

(ii) carrying on business (including a profession, a trade, manufacturing, or an undertaking carried on for pecuniary profit),

including in partnership with another person:

(iii)working for a trust in a business (as defined in paragraph (ii)) carried on by the trust;

*delete whichever does not apply.

2 And I have worked/will have worked* as an employee/self-employed* at least an average of 10 hours a week over any 26 of the

weeks immediately preceding:

(a) the expected date of delivery of my child/children*

(b) the first date on which I/my spouse or partner* became the primary carer in respect of the child/children*

*delete whichever does not apply.

3 And to the best of my knowledge, the income I have provided in this application is correct.

And I make this solemn declaration conscientiously believing the same to be true by virtue of the Oaths and Declarations Act 1957.

Signature

Declared at:

Place

Day

Month

Year

Signature of Justice of the peace or other person authorised to take a statuory declaration

Checklist

Care verification:

Work verification:

Expectant mother:

You must have completed one of the following (see page 3 to

confirm which one):

You must attach:

proof of pregnancy from your lead maternity carer or

Employer declaration

doctor showing your EDD

your baby’s birth certificate.

Chartered accountant's or tax advisor's declaration

Other primary carer:

You must attach formal documentation confirming the care

Statutory declaration.

arrangement:

a certified copy of a court order placing the child in your

care,

Pre-term birth:

or if you do not have a court order,

If you ticked yes at question 3, you must attach:

a letter from the Ministry for Vulnerable Children, Oranga

proof of pregnancy from your lead maternity carer or doctor

Tamariki or your social worker confirming the care

showing your original EDD

arrangement,

and

or if you have neither of these,

the child's birth certificate if it has been issued, or a medical

complete a statutory declaration (IR880D) that the child is

certificate or hospital records confirming the date of birth.

in your care.

Please securely attach all documentation

Complete the check list before sending your application to Inland Revenue.

RESET FORM

Make sure you have signed and dated the application on page 3.

Send your completed application to: Inland Revenue, PO Box 39090, Wellington Mail Centre, Lower Hutt 5045

Page 5

Form Ir880 - Paid Parental Leave (Ppl) Application Page 7

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