When you are experiencing serious hardship or financial difficulties you can apply to be considered for relief from payment of a debt. This form enables you to apply for relief and depending on your circumstance you will also be required to complete additional forms showing your financial position and attach them with this application.

Adobe Acrobat PDF | 43KB | 1 Page

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.

Complete this form and attach as supporting information when you are making an application for relief from payment of a debt.

Your IRD number - if you do not have this call us on 0800 227 774.

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

After you finish

Please print and sign the completed form and send to your nearest Inland Revenue office.
You may wish to keep a copy for your personal records.
You will also need to complete the following form(s) and attach them:

Individuals not in business:

• Statement of financial position - individuals (IR40).

Individuals in business and non-individuals:

• Statement of financial position (IR590).
• Twelve month cash flow forecast (IR591).