Fillable Printable Registration of Voluntary Agreement for Child Support Form
Fillable Printable Registration of Voluntary Agreement for Child Support Form
Registration of Voluntary Agreement for Child Support Form
Page 1
Receiving carer’s details
1
IRD number
(8 digit numbers start in the second box.
)
2
Name (Tick one)
Mr Mrs Miss Ms
First name(s)
Surname
3
Home address
Street address
Town or cityPostcode
4
Postal address (if different from
above)
Street address or PO Box
Town or cityPostcode
5
Contact details
( )
( )
( )
Day Evening Mobile
Email
6
Is the receiving carer on a
NewZealand benet?
NoYes
Work and Income customer number
7
Bank account to pay child support
into
Bank nameBranch
Account name
Bank Branch Account number Suffix
Child Supportwww.ird.govt.nz/childsupport
IR 102
Registration of voluntary agreement for child support
Use this form to register or
make changes to a voluntary
agreement for the payment of
child support.
Please answer every question.
Both parties to the agreement
must sign this form.
Any formula assessed child
support for the children
named in this application will
stop from the date we accept
your voluntary agreement.
Agreed payments will be
collected monthly from the
liable parent and passed on to
the receiving carer monthly.
If the receiving carer is on
a sole parent benefit, you
can only register a voluntary
agreement if the amount is
equal to, or more than, the
amount payable under a
formula assessment.
More information including who can
apply, can be found on our website
or read our fact sheet Child support
– voluntary agreements (IR 157).
If you need help completing this
form, you can call 0800221221.
April 2015
Page 2
Liable parent’s details
8
IRD number
9
Name (Tick one)
Mr Mrs Miss Ms
First name(s)
Surname
10
Home address
Street address
Town or cityPostcode
11
Postal address (if different from
above)
Street address or PO Box
Town or cityPostcode
12
Contact details
( )
( )
( )
Day Evening Mobile
Email
If a child doesn’t have an IRD number, you’ll need to apply for one.You can do this by completing an Application for an IRD
number – individual (IR 595) form.
The agreement start date needs to be a date in the future. If you don’t specify a future date we’ll use the date we receive this form.
Your agreement must be:
•for a “qualifying child”, this is a child who is under 19, a New Zealand citizen or ordinarily resident in New Zealand, is not
nancially independent and not living with another person in a marriage, civil union or de facto relationship
•for regular payments, and for at least $10 per week ($520 per year)
•signed by both the liable parent and receiving carer.
If you have a separate written agreement please attach a copy to this form.
Voluntary agreement details
If there are more than three children, please write their details on a seperate piece of paper and write your name and IRD number at
the top and attach it to this form.
14
First child
First name(s)
Surname
Date of birthIRD number
Day Month Year
Amount payable
Each week month year (Tick one)
Agreement start date
15
Second child
First name(s)
Surname
Date of birthIRD number
Day Month Year
Amount payable
Each week month year (Tick one)
Agreement start date
Child Supportwww.ird.govt.nz/childsupport
Page 3
16
Third child
First name(s)
Surname
Date of birthIRD number
Day Month Year
Amount payable
Each week month year (Tick one)
Agreement start date
Declaration
Both parties to the agreement must sign this form.
To the best of my knowledge the
information given is true and correct.
Receiving carer
To the best of my knowledge the
information given is true and correct.
Liable parent
Please send this completed form to: Child Support, PO Box 39010,Wellington Mail Centre, Lower Hutt 5045
Privacy
Meeting your child support obligations involves giving accurate information to Inland Revenue.We ask you for information
so we can assess your liabilities and entitlements under the Child Support Act 1991.
We may also exchange information about you with:
• some government agencies
• another country, if we have an information supply agreement with them
• Statistics New Zealand (for statistical purposes only).
If you ask to see the personal information we hold about you, we’ll show you and correct any errors, unless we have a lawful
reason not to. Call us on 0800 221 221 for more information. For full details of our privacy policy go to www.ird.govt.nz
(search keyword: privacy).
Child Supportwww.ird.govt.nz/childsupport
