Use this form for paying your NRWT deductions to us.

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.

Use this form to advise us of the total amount of NRWT you are paying.  This will be split into dividends, interest and royalties.

The total amount of NRWT that you will be paying to us in the three categories of:

• dividends
• interest, and
• royalties.

Please advise us (on this slip) if you have paid electronically.

If there is a difference between the NRWT deducted and the amount of payment you have enclosed (or paid electronically) please attach a letter of explanation.

Adobe Reader 9 http://www.adobe.com/products/reader/

After you finish

Please print, sign and attach your payment and post to your nearest Inland Revenue office.

You can detach the top portion of this form for your records.