About this Form

This form enables you to establish an automatic payment from your nominated bank account to Inland Revenue. The payments can be for a range of taxes including income tax, GST and FBT. You can also use this form to make additional payments on your student loan.

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.

When to use this form

This form can be used to:

• establish an amount to have transferred
• nominate the frequency or dates you want the transfers to take place
• change the arrangements established by an existing automatic payment authority.

What you will need

In order to successfully lodge this form with your bank you will need to provide:

• your account details
• the amount you would like transferred
• your IRD number, tax type and tax year the payments relate to
• a signed authorisation.

After you finish

Give the completed and signed form to your bank.

By lodging this authority you are also accepting the conditions set out on page 2 of the form. Depending on the terms and conditions that apply to your nominated account, your financial institution may charge a fee. Government charges may also apply. If you have any questions please contact your financial institution.

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