Please complete the following form:

EMPLOYER CHOSEN KIWISAVER SCHEME

It is agreed that your organisation (the Employer) selects the Staples Rodway KiwiSaver Scheme (the
Scheme) to be the Employer’s chosen KiwiSaver scheme for the purposes of sections 46 to 49 of the KiwiSaver Act 2006. Notice of that choice is
hereby given to the Commissioner of Inland Revenue.
Staples Rodway Super Fund Trustee Limited (the Trustee and Provider) acknowledges that the Scheme has been chosen as the Employer’s chosen
KiwiSaver scheme and agrees to provide access to the Scheme for the Employer’s employees.
The Employer agrees to verify the identity of each employee in accordance with the requirements of the Financial Transactions Reporting Act
1996 prior to that employee joining the Scheme. The Employer will keep records of that verification and provide access to those records to
the Trustee when reasonably requested by the Trustee.

Employer		IRD Number
Address
Your name		Email
Provider	Staples Rodway Super Fund Trustee Limited	Scheme	Staples Rodway KiwiSaver Scheme
IRD Number	91 092 700	IRD Number	91 092 204
	Level 11, Tower Centre 45 Queen Street Auckland		Level 11, Tower Centre 45 Queen Street Auckland

By submitting this form you have agreed on behalf of your employer for us to forward this completed form to:

The Commissioner
Inland Revenue Department
PO Box 1454
Hamilton