Gift statement IR 196December 2007

Estate and Gift Duties Act 1968

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Read the notes on the back before completing this form.Send two signed copies of the gift statements with any attachments to Inland Revenue,PO Box 2871, Christchurch. We will return one copy to you after it has been processed.

Duties1. Contact person for enquiries about this form (this may be a solicitor or other agent)

Contact person’s full name Phone number

Contact person’s street address or PO Box and town or city

2. Donor’s details (the person making the gift)Donor’s full name

Donor’s IRD number Donor’s occupation

Donor’s postal addressStreet address or PO Box number

Suburb, box lobby or RD Town or city

3. Donee details (the person receiving the gift)Please list the full names of those receiving the gift(s)

4. Gift detailsDate of gift (see Note 2)

Day Month Year

Details of property gifted, such as cash, land, reduction of debt

Less any consideration received (see Note 3)

Value of gift

Gross value

Other gifts within 12 months from the date of the current gift(s). Please list other gifts you have made within the last12 months. Include all gifts made to the above donee(s). If you have made more than two, please attach a sheet ofpaper with the details. If you have not made any other gifts within 12 months, write “nil”.

Date of gift (s) Details of gift (s) Value of gift (s)

Please attach a photocopy of any document that created or evidenced the gift (see Note 4).

5. Declaration My country of domicile is

To the best of my knowledge and belief the particulars shown above and the documents attached are true and correct.

Assessment of gift duty (to be completed by Inland Revenue)

This is your assessment for gift duty. If you wish to challenge this assessment you must do so within four months from the dateof this assessment.

Signature

Date

Offi ce use only

Notes

Note 1. Filling in the statementYou must complete an IR 196 gift statement when the gifts made by you in any 12-month period total more than $12,000. The 12-month period does not relate to a calendar or fi nancial year, but runs from the date at which you made the fi rst of the gifts that in total exceed $12,000.

Send two signed copies of the gift statement and any attachments to the address shown below within three months from the date of the gift. We will return one copy of the gift statement to you once it has been processed, together with a notice of assessment if there is any gift duty to pay.

Note 2. Date of the giftThe date of the gift is the date the gift becomes complete. This date can differ depending on the type of gift—the completion dates for common types of gifts are shown in our gift duty booklets (see “For more help” below).

Note 3. Consideration receivedThe consideration received is the monetary value of anything you received in return for the gift. Please attach to the statement full details of any consideration received.

Note 4. Evidence of giftPlease attach a copy of any document that created or evidenced the gift. Examples include:– the deeds of acknowledgment of debt and forgiveness or release of debt (this is required each time you forgive or release an amount of the debt)– any other supporting document, such as a valuation of property.These can be photocopies—originals are not required.

Note 5. DomicileYour domicile is the country where your permanent home is located and is not always the one in which you are resident for tax purposes. It is usually your country of origin, though an intention to live in another country permanently may be an indication of a domicile of choice. You cannot have more than one domicile at a time.

For more helpFor more help read our booklets, Gift duty (IR 194) or Gift duty – A guide for practitioners (IR 195). You can get them from our website or order copies by phoning INFOexpress—see below. For other gift duty enquiries, phone us on 0800 105 654.

Send completed gift statements to:Duties UnitInland RevenuePO Box 2871Christchurch

www.ird.govt.nz Visit our website for services and information. Go to:• Get it done online to fi le returns, register for services and access account information• Work it out to calculate tax, entitlements, repayments and due dates and to convert overseas income to

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INFOexpressINFOexpress is our automated phone service. You can order stationery (forms and guides) and request personal tax summaries using our natural language speech recognition system. This lets you use your voice instead of keying in numbers on the phone keypad. For all other services you’ll need to use a touch tone phone and key in numbers for options.Remember to have your IRD number with you when you call. It’s also helpful if you know the number or name of any forms or booklets you’re ordering. For personal information, such as account balances, you’ll also need an INFOexpress personal identifi cation number (PIN). You can get a PIN by calling 0800 257 777 and following the step-by-step instructions.You can call INFOexpress for the following services between 6 am and 12 midnight, seven days a week:

• Forms and guides (speech recognition) 0800 257 773

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