4. Evidence of non-profit status

Duties Act 2001

Katie Rose Cottage Ltd.

Qualifying use statement (general insurance)
for exemption from insurance duty on a premium
for general insurance of property or an undertaking

I [name]

of [address]

am the Accountant / Secretary / Manager / Trustee of the above institution which is a registered charitable
institution under the Taxation Administration Act 2001. 1 enclose a copy of the registration letter issued by
the Commissioner of State Revenue.

I certify that the property will:

1. start to be used for a qualifying exempt purpose immediately after the insurance premium is paid
2. be used solely or almost solely for a qualifying exempt purpose for 1 year after payment of the premium

3. not be used for an employment or salary package of an officer or employee of the institution.

The property will be used for the following qualifying exempt purpose:

 

Describe purpose in detail:

 

 

DETAILS OF INSURANCE

Policy no. Type of risk (e.g. fire):

Location of property: Date of commencement of insurance:
Total sum insured: $ Premium: $

Proportion (if any) of the total sum insured not related to a qualifying exempt purpose: $

Proportion (if any) of the premium not related to a qualifying exempt purpose: $

Signature: Date: