Personal Info
Bank Details
Work Type
Vehicle Allowance
Expense Reimbursement
Summary
Your details
Bank Details
Please attach a blank deposit slip or complete the following.
Deposit Slip
Work Type
We are required to deduct withholding tax unless you have previously provided us with a certificate of exemption. If you have not already provided us with your completed IR330C please ensure that this is emailed to us as soon as possible
If you are claiming for multiple work types please complete a separate claim form for each work type.
Select Work Type
Accreditation Panel Chair
Accreditation Panel Member
Competence Assessment
Competence Review - Convenor
Competence Review - Panel
Competence Supervision
HPDT - Chair
HPDT - Panel
IQM Qualification Assessment
Mentor or Supervisor
Midwifery Council Meeting - Co Chair
Midwifery Council Meeting - Council Member
OSCE Assessor
PCC - Chair
PCC - Panel
Project work - enter rate as per contact
Staff expenses
Whakamatautau Komiti | Council Working Group
Select
1 Day Review
2 Days Review
Fees Sub Total
Less withholding tax (%)
Per IR330C
Are you GST Registered?
Y/N
YES
NO
Sub Total
Motor vehicle allowance
Please only complete this section if you are claiming mileage.
Select Vehicle Type
Petrol or Diesel
Petrol Hybrid
Electric
Kilometers per year
Less than or equal to 14000km
Greater than or equal to 14000km
Date
Travel From
Travel To
Travel KMs
Total
Subtotal (incl GST)
Expense Reimbursement
Please only complete this section if you are claiming additional expenses.
Please attach original receipts, claims without receipts cannot be processed.
Description
Attach Receipts
Total Incl GST
Subtotal
Payment Summary
Work Type Total Claim
Witholding Tax
GST
Total Payment
Submit