Tell us about yourself (ll in as much as you can)
1
Your IRD number
(8 digit numbers start in the second box.
)
2
Your name (Tick one)
Mr Mrs Miss Ms
Date of birth
Day Month Year
First name(s) Surname
If you are known by or have ever used any other names please give the details.
First name(s) Surname
3
If you want the other parent to know you by another name, please enter it here. Read the notes about "Alias names".
First name(s) Surname
4
Are there any safety reasons why you don't want the other parent to know your name? Yes No
(Please note: We don't give the other parent your contact details)
If you answered "yes" we may be able to take your name off correspondence sent to the other parent. If you have documents
supporting your safety reasons, attach a copy to this form. If we need more information we'll contact you. Please make sure we
have your correct contact details. Read the notes "Safety concerns about your name."
5
Your home address
Street address Suburb
Town or city Postcode Country
6
Your postal address (if different
from above)
Street address or PO Box Suburb
Town or city Postcode Country
Please tick if you prefer your child support mail to be sent to your postal address
7
Your contact details
( )
( )
( )
Day Evening Mobile
Email
Child Support www.ird.govt.nz/childsupport
Page 1
IR101
Child Support
December 2016
Application to assess child support
Complete this form if you want to apply for
child support for children that you are a parent
of. If you receive a sole parent benefit for these
children, you must apply for child support.
If you want to register an agreed amount for child
support, please complete a Registration of voluntary
agreement for child support (IR102) form.
If the care of your
child is shared
with someone
else, use our
online calculator
to see if you meet the criteria
for recognised care.
Read
the
notes
pages
to help
you understand
this form.
More
information
about child
support can
be found on
our website
www.ird.govt.nz/childsupport
8
Your bank account
Account name
Bank Branch Account number Suffix
9
Income
Do you receive, or have you applied to receive, a benet?
Yes No
If "yes", are your children included in this benet?
Yes No
If "yes", to either question above, please specify benet type. Work and Income number (if known)
Payment day Tuesday Wednesday Thursday
Do you have a job (including any
self-employed work)?
If "yes", who do you work for?
Yes
( )
Work name Phone
No - go to Question 10
Work address
Town or city Postcode Country
Tell us about the other parent (ll in as much information as you know)
Complete a separate application for each "other" parent. For example, if you have two children, and they have different parents,
you'll need to complete two applications.
10
Their IRD number Date of birth Age (if date of birth not known)
Day Month Year
11
Their name (Tick one)
Mr Mrs Miss Ms
First name(s) Surname
12
Are they known by another name? Give the name they use now or have used in the past.
First name(s) Surname
13
Are they a New Zealand citizen? Ye s No Don't know
Do they live overseas? Ye s No Don't know
Did they leave New Zealand in the last 12 months (excluding short-term holidays)? Ye s No
Don't know
14
Their home address
Street address Suburb
Town or city Postcode Country
15
Their postal address (if different
from above)
Street address Suburb
Town or city Postcode Country
16
Their contact details
( )
( )
( )
Day Evening Mobile
Email
Child Support www.ird.govt.nz/childsupport
Page 2
17
Income
Do they receive a benet?
Yes No Don't know
If "yes", please specify benet type Work and Income number (if known)
Do they have a job (including any
self-employed work)?
Yes No Don't know
If "yes", write who they work for here
( )
Work name Phone
Work address
Town or city Postcode Country
Tell us about your children (ll in as much as you can)
All children must have an IRD number. If they don't have one, read the notes pages to nd out how to get one.
Recognised care
We need to know if someone else cares for your child/children two nights per week (on average). Read the "Recognised care"
notes pages for more information.
Qualifying children (These are the children you want child support assessed for)
Read the notes pages to nd out about children who qualify for child support, and what we accept as proof of parentage and
date of birth.
18
Child 1
First name(s)
Surname
Date of birth IRD number
Day Month Year
Was this child born while the parents were married to each other? Ye s No
If the father is not named on the birth certicate, is paternity action
being taken?
Ye s No
What date did the child come into your care? From birth or from
Day Month Year
Is there a court order or agreement in place for the care of this child? Yes (attach copy) No
Do you provide more than ve nights per week (on average) of this
child's care?
Yes - go to next
child
No - continue
Your amount of care
Number of nights How often? Weekly Fortnightly Monthly Yearly
Full name of other carer
First name(s)
Surname
Other carer's amount of care
Number of nights How often? Weekly Fortnightly Monthly Yearly
Note: If your or the other carer's pattern of care for any child named in this form is not covered by the options above, please
provide the care details at Question 21 on page 5. Be sure to include the same details as shown here. If there are additional
carers for any child, please provide their details on a separate piece of paper. Be sure to include the same details as shown here,
and include your name and IRD number at the top of the page.
Child Support www.ird.govt.nz/childsupport
Page 3
19
Child 2
First name(s)
Surname
Date of birth IRD number
Day Month Year
Was this child born while the parents were married to each other? Ye s No
If the father is not named on the birth certicate, is paternity action
being taken?
Ye s No
What date did the child come into your care? From birth or from
Day Month Year
Is there a court order or agreement in place for the care of this child? Yes (attach copy) No
Do you provide more than ve nights per week (on average) of this
child's care?
Yes - go to next
child
No - continue
Tick here if the care details for this child are the same as for the rst child. If the care details for this child are
different, enter them in the elds below before going to the next question.
Your amount of care
Number of nights How often? Weekly Fortnightly Monthly Yearly
Full name of other carer
First name(s)
Surname
Other carer's amount of care
Number of nights How often? Weekly Fortnightly Monthly Yearly
20
Child 3
First name(s)
Surname
Date of birth IRD number
Day Month Year
Was this child born while the parents were married to each other? Ye s No
If the father is not named on the birth certicate, is paternity action
being taken?
Ye s No
What date did the child come into your care? From birth or from
Day Month Year
Is there a court order or agreement in place for the care of this child? Yes (attach copy) No
Do you provide more than ve nights per week (on average) of this
child's care?
Yes - go to
Question 22
No - continue
Tick here if the care details for this child are the same as for the rst child. If the care details for this child are
different, enter them in the elds below before going to the next question.
Your amount of care
Number of nights How often? Weekly Fortnightly Monthly Yearly
Full name of other carer
First name(s)
Surname
Other carer's amount of care
Number of nights How often? Weekly Fortnightly Monthly Yearly
If you need to tell us about more qualifying children, include their details on a separate piece of paper, giving the same details as
for the children above, and attach it to this form. Please include your name and IRD number at the top of the page.
Child Support www.ird.govt.nz/childsupport
Page 4
21
Please list any additional information that may help us work out recognised care levels, for example, if the arrangements are
different for school holidays
Dependent children. These can't be the children named in Questions 18-20 (as qualifying children) or children in your
care that you already pay or receive child support for.
You must be the parent of any dependent child. Read the notes pages to nd out about which children qualify as dependents
and about proof of parentage and date of birth.
22
Child 1
Full name
First name(s) Surname
Date of birth Their IRD number
Day Month Year
What date did the child come into your care? From birth or from
Day Month Year
Do you provide more than ve nights per week (on average) of this child's
care?
Ye s No - we will contact you
23
Child 2
Full name
First name(s) Surname
Date of birth Their IRD number
Day Month Year
What date did the child come into your care? From birth or from
Day Month Year
Do you provide more than ve nights per week (on average) of this child's
care?
Ye s No - we will contact you
24
Child 3
Full name
First name(s) Surname
Date of birth Their IRD number
Day Month Year
What date did the child come into your care? From birth or from
Day Month Year
Do you provide more than ve nights per week (on average) of this child's
care?
Ye s No - we will contact you
If you need to tell us about more dependent children, include their details on a separate piece of paper, giving the same details
as for the children above, and attach it to this form. Please include your name and IRD number at the top of the page.
Child Support www.ird.govt.nz/childsupport
Page 5
Declaration
To the best of my knowledge, the information I have provided on this form is true and correct.
By signing this declaration, I:
acknowledge I am a parent* of the child/children named on this application
understand Inland Revenue will complete a calculation using the formula and let me know if I will pay or receive child support
agree to advise Inland Revenue of any changes that could affect my child support (eg, if the children leave my care)
understand that a change in either parent's circumstances (eg, care of the child, or income) could mean a change to who pays or
receives child support.
* You may wish to seek legal advice before acknowledging you are the parent of the children named in this application. By signing this form you are
acknowledging you are the parent of the children. This means you can be made liable to pay child support.
Please send this completed form to: Child Support, PO Box 39010, Wellington Mail Centre, Lower Hutt 5045
What happens next?
This form is a request for an assessment of child support. We need to complete a calculation before we know who should pay and
who should receive child support.
If we determine you'll receive payments from a liable parent, we'll notify you of how much you're entitled to receive.
If we determine you're the liable parent we'll notify you of how much you need to pay and by when, so you can organise your
payments.
If you receive a benet from Work and Income:
child support is only paid to you if it is more than the amount of sole parent benet you receive. The liable parent's payments will
go to the Government to help cover the cost of your benet.
and you're a liable parent, we'll contact Work and Income to organise your child support payments to be deducted from your benet.
Privacy
Meeting your child support obligations means giving us accurate 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 for the personal information we hold about you, we’ll give it to 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).
Work and Income use only
1. Has the receiving carer indicator SDT1A or SDT2A been set to "Y"?
Yes No
2. Benet start date
Day Month Year
3. Benet rate - weekly
4. Benet type (code)
25
Please complete this question for children named in this application who are 18 or turn 18 within the next
two months of lling out this form.
Child's full name
Is the child enrolled at and attending a registered
school in New Zealand or an overseas school?
Ye s No
Ye s No
Ye s No
26
Child support from the Australian Department of Human Services
Is anyone currently living in Australia claiming child support from the
Australian Department of Human Services for the same children?
Yes - read the notes pages No
Child Support www.ird.govt.nz/childsupport
Page 6
RESET FORMRESET FORM
Notes to help you complete this form
Who is a parent?
A parent is a person who:
is the birth or legally adoptive parent of a child
was married to the other parent when the child was conceived or born
has acknowledged before a court, or in writing, that they are a parent of the child and a court has not overturned this
has been declared a legal step-parent by the Family Court
a court has made a paternity order against in respect of the child.
Alias names
You can ask to use an alias name when you need to protect your privacy. For example, you don't want the other parent to know your
new married name. We won't accept a nickname.
Safety concerns about your name
If you believe that using your real name will cause safety concerns for you, a carer, or your child, we may be able to leave your
name out when communicating with the other parent.
To support your safety reasons remember to attach any relevant documents to this form. For example a court order, police report, a
letter from a social worker or Work & Income, or a letter from your doctor.
Proof of date of birth
You will need to supply one of the following for proof of date of birth:
full New Zealand birth certicate
overseas birth certicate
passport
certicate of New Zealand citizenship
certicate of identity
photo driver's licence
18+ card issued by the Hospitality Association.
Proof of parentage
You will need to supply one of the following for proof of parentage:
the child's full New Zealand birth certicate
the child's full overseas birth certicate (with a certied English translation if necessary)
adoption order for the child
a paternity order for the child made by a New Zealand or overseas court
a completed Acknowledgement of paternity for child support (IR106) form*
a document signed by the parent acknowledging they are the child's parent*
a copy of the Family Court’s declaration of step-parentage.
*These documents can't be used to prove the child's date of birth. You must also send in a copy of one of the documents in the list under "Proof of
date of birth".
If there's no proof of parentage, we may tell the person named that this application has been made naming them as a
parent of the child/children.
Recognised care
The child support formula recognises the costs of raising a child and shares these costs between the parents based on their
income and care. Care is recognised in the following situations:
If a person provides more than 263 nights per year, or 5 nights a week on average (more than 72% of the time) of a child's care,
theirs is the only care we take into account in the child support formula calculation.
If a parent cares for the child at least 103 nights per year, or 2 nights per week (28% of the time) that care is taken into account
in the child support formula calculation.
A non-parent carer, eg, a grandparent, has care of a child for at least 128 nights per year, or 5 nights per fortnight (35% of the
time).
Use our online calculator at www.ird.govt.nz/childsupport to work out your care levels. You can then print and attach it to this
form.
Agreement or court order
If you have an agreement or court order detailing the care arrangements for your child/children, we can use this to work out your
recognised care level.
Child Support www.ird.govt.nz/childsupport
Notes
Qualifying children
To qualify for child support, a child must be:
under 18 years of age or 18 years of age and enrolled at and attending a registered school in New Zealand or an overseas
school, and
a New Zealand citizen or ordinarily resident in New Zealand.
The child cannot be:
receiving a benet or student allowance, or working 30 hours or more a week (on average), or
living with another person in a marriage, civil union or de facto relationship.
Dependent children
A dependent child is:
your child by birth, legal adoption or for whom you are a legal step-parent (as declared by the Family Court)
under 18 years of age or 18 years of age and enrolled at and attending a registered school in New Zealand or an overseas
school and in your care, for example, living with you, or maintained as a member of your family but living somewhere else,
eg, boarding school. If the child is living with you, you must be caring for the child at least two nights per week (28% of the time).
(Read the note above on "Who is a parent?")
A dependent child cannot be:
receiving a benet or student allowance, or working 30 hours or more a week (on average), or
living with another person in a marriage, civil union or de facto relationship.
a child in relation to whom any person is a liable parent or receiving carer for whom, under the law of another country, a person
is required to make payments that are of the same nature as child support.
Paternity orders
If the father isn't currently named on the child's birth certicate you can apply for a paternity order. Once a paternity order is made,
we may be able to start child support from when we receive this application. It's important that you send any paternity order to us
as soon as it is made.
If you need more information about paternity orders, please go to the Ministry of Justice website www.justice.govt.nz (search
keyword: paternity).
IRD numbers for children
If your child doesnt have an IRD number you’ll need to apply for one before your child support application can be accepted. You
can do this by completing an Application for an IRD number - individual (IR595) form.
However, if your child wasn’t born in New Zealand, doesn’t have an IRD number and isn’t a resident of New Zealand, you don’t
need to apply for or provide an IRD number.
Child support from the Australian Department of Human Services
We have a reciprocal agreement with Australia for the assessment and collection of child support payments. The agreement
allows both countries to enforce payments of child support owing in the other country, where payments are not being made.
Only the country where the carer lives can make an assessment. If you have an assessment made in Australia but now live in
NewZealand, contact the Australian Department of Human Services ( DHS) on 0800 440 953 to let them know.
If you are a carer living in Australia you must apply for child support through the Australian DHS. Call us on 1800 504 042 if you
need any help.
For more information about any of the above, please go to our website www.ird.govt.nz/childsupport
Child Support www.ird.govt.nz/childsupport
Notes
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