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IR 219 January 2011
Student loan overseas basedborrower repayment application
Student Loan Scheme Act 1992
Please complete this orm i you want to negotiate your overseas
based borrower repayment obligations. Send the completed orm
to:Inland RevenuePrivate Bag 1932DunedinNew Zealand
All in ormation on this orm is con dential.Tis orm may be
completed by the borrower or someone acting on their behal . You
can elect someone to act on your behal bysending us a letter
stating this, by calling us, or by completing the Elect someone to
act on your behalf (IR 597) orm. You can get this
orm romwww.ird.govt.nz or by calling:0800 257 773 within New
Zealand, or64 4 978 0767 outside New Zealand
I you have any questions about this orm or your student loan,
please call us between 9 am and 4.30 pm weekdays on:03 951 2020
within New Zealand, or64 3 951 2020 outside New Zealandor email
[email protected]
Full name o borrower Mr Mrs Miss Ms
First names
Surname
IRD number (8 digit numbers start in the second box. )
Mailing addressStreet address
own or city Country
Post code Phone
or New Zealand address
Street address
own or city Phone
Email address
Number o dependants(including spouse or partner i
applicable)
Date o departure (i known)Day Month Year
I want to negotiate my overseasbased borrower repayments or
my
student loan because:
I ofer to pay: or overseas based borrowersrepayments or the tax
year 1 April to 31 March
Weekly income and expenses in New Zealand dollars:
(tick one) Actual amount Estimated amount Actual amount
Estimated amount
Weekly Income Weekly ExpensesSalary or wages
Rent/board/mortgage
Pension or bene t Power/phone etc
Interest or dividends Food
Rent(s) ransport
Spouse or partners income Other (please speci y)
TOTAL TOTAL
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Assets and liabilities Enter all business and private assets and
liabilities.
Assets (show detailsthis must include any assets you have
overseas as well as in New Zealand)
Residential property (market value) Value
Other property (market value) Value
Vehicles, or example, car,boat, caravan (please includethe
registration number)
Model and year Value
Model and year Value
Bank accounts Bank and branch
Account number Balance
Bank and branch
Account number Balance
Other accounts (creditunion, building society etc) Account
Balance
Household efects Value
Li e insurance andsuperannuation policies
Company Surrendervalue
Company Surrendervalue
Money owed Owed to you by Value
Other assets Shares Value
Debentures Value
Other ( or example, bonus bonds, loans, personal efects)
Value
Total assets
Liabilities and debts (show detailsthis must include any
liabilities or debts you have overseas as well as in New
Zealand)
Mortgages Bank or institution Value
Loans Bank or institution ValueBank or institution Value
Bank overdra t Bank or institution Amount
Bank or institution Amount
Credit cards ype Limit Balance
owing
ype Limit
Balanceowing
Hire purchases Item Balance topayDate purchased Finishdate
Item Balance topay
Date purchased Finishdate
Other debts (Ministryo Justice, Work andIncome etc)
Name o debt Value
Name o debt Value
Total liabilities
Declaration
I declare the details contained in this formare true and
correct.
Signature
Date
/ /
I you are completing this orm on behal o the borrower, please
state: your name and relationship to them
(eg amily member, riend or other) your contact address
your phone number
