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

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

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

  • 1 signature
  • 7 check-boxes
  • 289 other fields

Country of origin: NEW-ZEALAND
File type: PDF

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To the employer:
...........................................................................
...........................................................................
...........................................................................
Return the completed form to:
...........................................................................
...........................................................................
...........................................................................
The information this form requests, about the person below, is collected because it is relevant to the
services that the Ministry of Social Development (or our Contracted Service Provider) provides. It may
also be shared with the client.
The income details we need are for:
the 52 week period ending
Day Month Year
OR
the period from
Day Month Year
to
Day Month Year
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 number
( )
Email address
We are asking for this information under the authority of the legislation of the Social Security Act 1964 and the Housing Restructuring
and Tenancy Matters Act 1992.
Person’s
details
Client number
Person’s full name
First and middle names Surname or family name
Person’s date of birth
Day Month Year
Employment and earnings
information for reviews
Page 1V26 – JUL 2014
Employer to complete
Tell us when
the person
worked for you
When did the person start working for you?
Day Month Year
What was the person’s tax code?
Does the person still work for you?
No
Go to question 5
Yes
HOW TO ANSWER Q4
:
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.
What type of work does this person do?
Full-time Part-time Casual
Seasonal Self-employed Voluntary
Go to question 7
Details if the
person no
longer works
for you
What was the last day the person worked for you?
Day Month Year
HOW TO ANSWER Q6
:
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 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
$ $
1
2
3
4
5
6
Page 2 V26 – JUL 2014
Breakdown
of the
person’s
income
What has the person been paid, for the period given on page one.
If your payment system can produce the information requested in question
seven, you can attach a printout.
Please fill in the table below. Do not include any amounts you answered for question six.
Week ending
Amount
before tax
Amount
after tax
Hours
worked
1 / / $ $
2 / / $ $
3 / / $ $
4 / / $ $
5 / / $ $
6 / / $ $
7 / / $ $
8 / / $ $
9 / / $ $
10 / / $ $
11 / / $ $
12 / / $ $
13 / / $ $
14 / / $ $
15 / / $ $
16 / / $ $
17 / / $ $
18 / / $ $
19 / / $ $
20 / / $ $
21 / / $ $
22 / / $ $
23 / / $ $
24 / / $ $
25 / / $ $
26 / / $ $
Week ending
Amount
before tax
Amount
after tax
Hours
worked
27 / / $ $
28 / / $ $
29 / / $ $
30 / / $ $
31 / / $ $
32 / / $ $
33 / / $ $
34 / / $ $
35 / / $ $
36 / / $ $
37 / / $ $
38 / / $ $
39 / / $ $
40 / / $ $
41 / / $ $
42 / / $ $
43 / / $ $
44 / / $ $
45 / / $ $
46 / / $ $
47 / / $ $
48 / / $ $
49 / / $ $
50 / / $ $
51 / / $ $
52 / / $ $
HOW TO ANSWER Q8
:
Please include
payments described
in questions 6 and 7
and/or bonus payments,
gratuities, etc.
What was the total amount the person received for the period given on page
one, including any extra payments they received?
Before tax After tax
$ $
HOW TO ANSWER Q9
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, for the period given on page one?
No Yes
Please tell us about the type of payment and its value
Type of payment Value
$
$
$
7
8
9
Page 3V26 – JUL 2014
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 name
Contact person’s name
Contact person’s telephone number
( )
Contact person’s email address
Employer’s or delegated person’s signature Date
Day Month Year
Page 4 V26 – JUL 2014
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signature
click to edit
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Completed 11 February 2021

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