Fillable Employment and earnings information for applications (Ministry of Social Development New Zealand)

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Employment and earnings information for applications (Ministry of Social Development New Zealand)

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The Employment and earnings information for applications (Ministry of Social Development New Zealand) form is 4 pages long and contains:

  • 0 signatures
  • 9 check-boxes
  • 100 other fields

Country of origin: NEW-ZEALAND
File type: PDF

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Page 1 V06 – OCT 2021
To:
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............................................................................................
............................................................................................
Return the completed form to:
............................................................................................
............................................................................................
............................................................................................
............................................................................................
In this form we (the Ministry of Social Development or our Contracted Service Provider) ask for employment
and earnings information about the person named below. They’ve given us permission to get this information
from you so we can work out if they qualify for any help from us. We may share the information you give us on
this form with them.
Please complete this form and send it back to us by
Day Month Year
Please contact me if you have any questions.
Thank you.
MSD staff member’s name
Phone number ( ) Fax ( )
Email
Person’s
details
Client number
First and middle names Surname or family name
Date of birth
Day Month Year
Written
permission
I give the Ministry of Social Development (or my Contracted Service Provider)
permission to get my information from the employer named above.
Client’s signature Day Month Year
Verbal
permission
The person named above has given verbal permission to the Ministry of Social
Development (or our Contracted Service Provider) to get their information
from the employer named above.
I have explained the information we’re asking for in this form.
The person is able to confirm this.
Staff member’s name Day Month Year
Employment and earnings
information for applications
Page 2 V06 – OCT 2021
Employer to complete
Tell us if the
person is
working for you
Is the person currently working for you?
If the person has stopped working temporarily (for example because they’re sick) and you’re not
currently paying them, you should answer “No” for thisquestion.
No
Go to question 2
Yes
Go to question 5
Details if the
person no
longer works
for you
What was the last day the person worked for you?
Day Month Year
Why did the person stop working for you?
They were made redundant/laid off
90 day employment trial has ended
Please explain why below
Contract/seasonal work ended
Please explain why below
Other
Please explain why below
HOW TO ANSWER Q4
:
Holiday pay includes
long-service leave
payments and
termination pay
includes payments
in lieu of notice.
Did the person get any of the following payments from you when they left?
No
Yes
Please tick the box and write in the amounts
Before tax After tax
Sick pay
$
$
Holiday pay
$
$
Termination pay
$
$
Redundancy pay
$
$
Other
$
$
Go to question 8
1
2
3
4
Page 3V06 – OCT 2021
Details if the
person still
works for you
When did the person start working for you?
Day Month Year
HOW TO ANSWER Q6
:
By full-time, we
mean generally
working at least
30 hours a week.
By part-time, we
mean generally
working at least
15 hours a week.
HOW TO ANSWER Q7
:
If their income varies
week to week, provide an
average (for example an
average of their last four
weeks’ pay).
What type of work does this person do?
Full time Part time Casual
Seasonal Self-employed Voluntary
How much does the person usually earn each week?
Before tax After tax
$
$
Breakdown
of the
person’s
income
What has the person been paid, in the last four weeks, or until the date they
stopped working for you?
Week ending Before tax After tax
1.
/ / $ $
/ / $ $
/ / $ $
/ / $ $
2.
3.
4.
HOW TO ANSWER Q8, Q9
AND Q10
:
If your payment system
can produce the
information requested in
questions 8, 9 and 10 you
can attach a printout.
Please include any
payments described
in question 4
and/or bonus payments,
gratuities, etc.
What was the total income you paid this person in the last 52 weeks, or until
the date they stopped working for you?
Before tax After tax
$
$
What was the total income you paid this person in the last 26 weeks, or until
the date they stopped working for you?
Before tax After tax
$
$
HOW TO ANSWER Q11
:
Other types of
payment include
advantages such
as free or subsidised
goods and services
(for example, free
food, subsidised
accommodation).
Did the person receive any other types of payment from you, apart from
money, in the last 52 weeks?
No Yes
Please tell us about the types of payment and their value
Type of payment Value
$
$
$
What tax code did the person use for this job?
5
6
7
8
9
10
11
12
Page 4 V06 – OCT 2021
Signature
The information I have provided is a true and complete match of the records held in this office.
I have authority to provide information for this business/company.
Business/Company’s name
Contact person’s name
Contact person’s details
Phone number ( )
Email
Employer’s or delegated person’s signature
Day Month Year
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Completed 14 March 2022

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