Fillable Including a partner form If you get a (Ministry of Social Development New Zealand)

Fill Online, Printable, Fillable, Blank Including a partner form If you get a (Ministry of Social Development New Zealand) Form

Use Fill to complete blank online MINISTRY OF SOCIAL DEVELOPMENT NEW ZEALAND pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Including a partner form If you get a (Ministry of Social Development New Zealand)

On average this form takes 105 minutes to complete

The Including a partner form If you get a (Ministry of Social Development New Zealand) form is 35 pages long and contains:

  • 0 signatures
  • 42 check-boxes
  • 400 other fields

Country of origin: NEW-ZEALAND
File type: PDF

Use our library of forms to quickly fill and sign your Ministry of Social Development New Zealand forms online.

BROWSE MINISTRY OF SOCIAL DEVELOPMENT NEW ZEALAND FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 R31 – APR 2020
Including a partner
form
If you get a benefit from Work and Income and now have a partner, your partner will need to be
included in your benefit and may get payments as well.
If you and your partner are both under 20 years old and you have dependent children, you may qualify
for Young Parent Payment. Please talk to us about this.
Before your partner can be included in your benefit:
• you need to answer some questions (pages 3 to 5)
• your partner will need to answer questions in the Partner form (pages 7 to 14)
• you’ll both need to read and complete the obligations and privacy section
(pages 15 to 19)
• you’ll both need to sign the form (pages 21 and 23).
You’ll need to bring proof of who you are.
Please bring some identification that you’ve given us before, such as a driver licence or
passport, or your Community Services Card.
Proof of who you are:
If you were born in New Zealand, bring one type of official identification
that has your full legal name and your date of birth (for example, your birth
certificate, passport, driver licence, firearms licence, deed poll).
If you were born overseas, bring proof that you have a right to live in New
Zealand (for example, a citizenship certificate, a NewZealand passport,
a passport from another country with residence class visa or proof of
permanent residence).
If your name has changed, bring your marriage certificate, deed poll, or
other proof of the name change.
All people applying need to bring two more documents that help to prove
who you are (for example, a marriage certificate, bank statement, phone or
power account, driverlicence).
A form or letter from Inland Revenue showing your tax number
Proof of your bank account details, such as a bank statement or deposit slip
One of the documents above must be at least two years old.
There are more things you and your partner need to bring in the table over
the page.
What you
need to do
What your
partner
needs to
bring
INFORMATION NOTE
:
Documents need to be
originals, or copies of
documents that have
been certified as a true
copy by a Solicitor/Lawyer,
Notary Public, Registrar
of the Court or Justice of
thePeace.
Page 2 R31 – APR 2020
Depending on your answers you both may also need to
bring these other documents. For you
For your partner
(if you have one)
Proof of your assets and their value.
Proof of payments, if you receive a benefit, allowance or
pension from overseas.
Full birth certificates for each dependent child in your care.
Your marriage or civil union certificate, for your relationship.
Your business accounts, if you have your own business.
Proof of any before-tax income for the 52 weeks, before the
application (for example, wages, holiday pay and any other
income).
Trust documents, if you are involved in a trust (for example,
trust deed, deed of debt, gift statements, accounts).
You must give us all the information we need.
If you do not have all the information we need, talk with us and we may be able to help.
If we find out later that any information you give us is not true, or that you knew information you
should have told us and did not tell us, we may stop paying your benefit. You might need to pay
money back, we may impose a penalty, and you could be prosecuted.
Other things
you need to
bring
Page 3 R31 – APR 2020
Including a partner
form
Please answer questions 1 to 13 to have your partner included in your benefit.
Tell us about yourself
Write your client number here. This number can be found on your Community Services Card.
Client number
Tell us your
details
What is your full name?
First and middle names Surname or family name
What date were you born?
Day Month Year
Tell us how
we can
contactyou
HOW TO ANSWER Q3
:
If you live in a rural
area, flat/house
numbercould
include your RAPID
number, firenumber,
emergencyservices
number.
HOW TO ANSWER Q4
:
Mailing address can
include a POBox, rural
deliverydetails, or
C/Oaddress.
HOW TO ANSWER Q5
:
Please only give
us contact details
you’dlikeus to use.
Where do you live?
Flat/House number Street name
Suburb
Town/City
Is your mailing address different from where you live?
No Yes
Tell us your mailing address
How else can we contact you?
Tick the best way for
us to first contact you
Home phone ( )
Mobile phone ( )
Other phone ( )
Do you agree to get emails from us?
No Yes
Tell us your email address
I don’t have an email address
1
2
3
4
5
6
Page 4 R31 – APR 2020
Tell us about the people in your household
Tell us about
your partner
What is your partner’s full name?
What is your partner’s date of birth?
Day Month Year
ATTACHMENT FOR Q9
:
Bring your marriage or
civil union certificate for
your current relationship.
What is your relationship status with your partner?
Tick one of the following boxes
Married In a civil union In a relationship
What date did your relationship start?
Day Month Year
Tell us
about your
dependent
children
HOW TO ANSWER Q11
:
Please give the names
of children you support
financially and who live
with you as a member of
your family, including:
• your own children
• adopted children
• stepchildren
• children at
boarding school
• grandchildren /
mokopuna.
The child’s name should
be the same as on the
child’s birth certificate.
Tell us the names of all
parents of each child.
ATTACHMENT FOR Q11
:
Bring the birth certificate
for each dependent child.
Do you have dependent children in your care?
No
Go to page 7
Yes
Please provide details below
Child 1
Full name Date of birth
Day Month Year
Relationship to you
Parent 1: Full name Parent 2: Full name
Child 2
Full name Date of birth
Day Month Year
Relationship to you
Parent 1: Full name Parent 2: Full name
7
8
9
10
11
Page 5R31 – APR 2020
Child 3
Full name Date of birth
Day Month Year
Relationship to you
Parent 1: Full name Parent 2: Full name
Child 4
Full name Date of birth
Day Month Year
Relationship to you
Parent 1: Full name Parent 2: Full name
If you need to include more than four children in your application, please write these details
about each one on a separate sheet of paper, and bring them with this application form.
Do you have a shared care arrangement for any of your dependent children?
No Yes
Please list the details below
Name of child
Hours a week in
your care
Name of person you have shared
carewith
INFORMATION FOR Q13
:
Working for Families
taxcredits are payments
to families with children
to help with day-to-day
living costs. People
getting a benefit who
have dependent children
generally qualify.
If you qualify for Working for Families tax credits do you want them paid with
your benefit?
No Yes
If you tick ‘yes’, we’ll tell Inland Revenue for you – so you don’t needto.
12
13
Page 6 R31 – APR 2020
Page 7 R31 – APR 2020
Including a partner
partner form
This form should be completed by the partner being included in the benefit.
Tell us about yourself
If you have received a benefit or extra financial help from us before, write your client number here if you know it.
This number can be found on your Community Services Card if you have one.
Client number
Tell us the
names you’ve
been known by
ATTACHMENT FOR Q1
:
Bring proof of who you
are. What you need to
bring is explained on
page1.
What is your full name?
Mr Mrs Ms Miss Other
First and middle names
Surname or family name
Is the name on your birth certificate the same as above?
No
Tell us the name that is on your birth certificate
Yes
First and middle names
Surname or family name
HOW TO ANSWER Q3
:
For example, have you
had married names,
English names, changes
by deed poll, or aliases?
ATTACHMENT FOR Q3
:
Bring your marriage
certificate, deed poll,
or other proof of any
name change.
Have you ever been known by any other name?
No Yes
1.
2.
What name would you like us to call you?
The name I wrote in Question 1 The name I wrote in Question 2
Other
Write the full name
1
2
3
4
Page 8 R31 – APR 2020
Tell us more
about you
What date were you born?
Day Month Year
Are you:
Male Female Gender diverse
ATTACHMENT FOR Q7
:
Bring a form or letter
from Inland Revenue
showing your tax number.
What is your Inland Revenue tax number?
ATTACHMENT FOR Q8
:
You need to provide
proof of your bank
account details, such
as a bank statement or
deposit slip.
What bank account would you want your payments to be paid into?
The account is in the name of:
The account number is:
Bank Branch Account number Suffix
Tell us how
we can
contactyou
HOW TO ANSWER Q9
:
If you live in a rural
area, flat/house number
could include your RAPID
number, fire number,
emergency services
number.
HOW TO ANSWER Q10
:
Mailing address can
include a POBox, rural
delivery details, or C/O
address.
Where do you live?
Flat/House number Street name
Suburb
Town/City
Is your mailing address different from where you live?
No Yes
Tell us your mailing address
HOW TO ANSWER Q11
:
Please only give us
contact details you’d like
us to use.
How else can we contact you?
Tick the best way for
us to first contact you
Home phone ( )
Mobile phone ( )
Other phone ( )
Do you agree to get emails from us?
No Yes
Tell us your email address
I don’t have an email address
5
6
7
8
9
10
11
12
Page 9R31 – APR 2020
Tell us your
ethnicity
INFORMATION FOR Q13
:
We collect this
information for statistics
we use in research and
future development work.
Tick the group(s) you most identify with.
Māori
Which tribe(s) or iwi?
New Zealand
European
Niuean Samoan Indian
Other European Tokelauan Tongan Chinese
Cook Island Māori
Other
Please write below
Don’t want to answer
Tell us
about your
residence
status
HOW TO ANSWER Q14
:
This means you consider
New Zealand your home,
you’re a legal resident,
you usually live here and
you intend tostay.
ATTACHMENT FOR Q14
:
If you answered ‘no’ you
will need to provide proof
of your assets and their
value (page 14).
Do you usually live in New Zealand?
No Yes
What best describes your residence status in New Zealand? Tick only one box.
New Zealand citizen
bybirth
Go to question 18
Granted New Zealand
citizenship
Date citizenship granted
Go to question 16
Day Month Year
Granted permanent
residency
Date permanent
residence granted
Go to question 16
Day Month Year
Other
What is your residence status?
When did you arrive in New Zealand?
Day Month Year
What country were you born in?
HOW TO ANSWER Q18
:
Please answer
even if you’re a
New Zealand
citizen by birth.
Have you lived in New Zealand continuously for at least two years since you
became a New Zealand citizen or permanent resident?
No Yes
13
14
15
16
17
18
Page 10 R31 – APR 2020
Tell us if you
have lived
or worked
overseas
INFORMATION FOR Q19
:
Periods of overseas
residence may:
• affect entitlement
to some benefits
• mean you’re eligible for
an overseas
benefit or pension.
For more information,
phone 0800 777 227.
HOW TO ANSWER Q19
:
Your reason for being
in a country may be
that you were there
for a working holiday,
you were living there,
you were born there.
Have you ever lived or worked in any countries outside of New Zealand?
No
Go to question 22
Yes
Please list details below
Name of country
Date you entered
this country
Date you left
this country Reason for being in this country
Do you receive or qualify for a social security benefit, pension or allowance
from overseas?
No
Go to question 22
Yes
Tick the box that best describes your benefit, pension or allowance
Retirement or old age Superannuation
Disability or health
condition
Widow or survivor Child or dependent War related
Other
ATTACHMENT FOR Q21
:
You’ll need to show
usproof of these
payments, such as a
pension certificate.
If you ticked ‘yes’ for question 20, please give details of the payments
you get.
Payment 1 Payment 2
What country does the payment come from?
How much do you get each time the payment
is made (in overseas currency)?
Is this amount before or after tax?
How often do you get the payment
(for example, weekly, fortnightly, monthly)?
What is the name of your pension, allowance
or benefit?
What is the payment reference number?
Tell us
whether you
are a veteran
Have you served with the New Zealand Armed Forces?
No Yes If you’ve ticked ‘yes’, you may be entitled to a:
• Veteran’s Pension (for more information call 0800 650 656), and/or a
• War Disablement Pension or associated payments
(formore information call Veterans’ Affairs New Zealand on
0800 4 VETERAN (0800 483 8372)).
19
20
21
22
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
Page 11R31 – APR 2020
Tell us about your work
Tell us about
your current
work
By ‘work’ we mean any employment for which you get paid or get other
advantages for, such as free or subsidised board, payments in kind, or
drawings from a business.
Are you working?
No
Go to question 28
Yes
HOW TO ANSWER Q24
:
By full-time, we mean
yougenerally work at least
30 hours a week.
INFORMATION FOR Q24
:
If you have more
than onejob please
record details of your
other employers on a
separatesheet of
paper.
For each job include the
information asked for in
questions 24, 25 and 26.
What type of work do you do?
Full-time Part-time Casual
Seasonal Self-employed Voluntary
Who are you working for?
Employer’s name
Employer’s contact details
Address
Phone number ( ) Fax ( )
Email
HOW TO ANSWER Q26
:
Include the amount
you’re paid and also
the value of things you
get from your employer
instead of money.
If your income varies
week to week – provide an
average (for example the
average of your last four
weeks pay).
How much are you paid each week?
Type of payment (include goods or services) Amount before tax Amount after tax
1.
$ $
$ $
$ $
$ $
2.
3.
4.
INFORMATION FOR Q27
:
Paid Parental Leave is
paidto eligible parents to
care for their newborn or
newly adopted child. It’s
paid by Inland Revenue.
You may get Best Start
tax credits when the Paid
Parental Leave ends.
Have you applied, or will you apply, for Paid Parental Leave?
No
Go to question 28
Yes
Please write the details below
Which child is it for?
How much is it each week?
$
What date will it end?
Day Month Year
23
24
25
26
27
Page 12 R31 – APR 2020
Tell us about your income and assets
Tell us
about
income
in the last
52 weeks?
ATTACHMENT FOR Q28
:
Bring a copy of your
business accounts.
INFORMATION FOR Q28
:
In this application form,
‘partner’ means the
person you’re married
to or in a civil union or
relationship with, not a
business partner.
Did you get income from any of the following sources in the last 52 weeks?
Wages or salary No Yes
Termination pay No Yes
Redundancy pay No Yes
Accident compensation (eg ACC) No Yes
Income insurance (replacement/protection) No Yes Jointly with partner
Farm or business income No Yes Jointly with partner
Payments from self employment or contractwork No Yes Jointly with partner
Interest from savings, investments, or bonds No Yes Jointly with partner
Dividends from shares, unit trusts, or
managedfunds
No Yes Jointly with partner
Income from rents No Yes Jointly with partner
Payments from boarders or flatmates No Yes Jointly with partner
Child Support payments No Yes
Other income for a child No Yes
Maintenance payments No Yes
Payments from a former partner No Yes
Student Allowance, scholarship, or Student Loan
living cost payments
No Yes
Overseas pension, benefit or allowance payments No Yes
Other superannuation or retirement scheme
income (government or private)
No Yes
Income from an estate, if you’ve inheritedmoney No Yes Jointly with partner
Income from trusts No Yes Jointly with partner
Other No Yes Jointly with partner
ATTACHMENT FOR Q29
:
You need to show us
proof of income you’ve
received in the last 52
weeks.
Did you answer ‘yes’ or ‘jointly with partner’ to any of the sources of income
listed in question 28?
No Yes
Tell us the total before-tax amounts, for the last 52 weeks
Payment made to?
Where did the income come from? You Jointly with partner
$ $
$ $
$ $
$ $
$ $
28
29
Page 13R31 – APR 2020
HOW TO ANSWER Q30
:
Other types of
payment include
advantages such
as free or subsidised
goods and services
(for example, free
food, subsidised
accommodation).
Did you get other types of payment apart from money in the last 52 weeks?
No Yes
Please tell us about the type of payment and its value
Type of payment Where did it come from? Its value
$
$
$
HOW TO ANSWER Q31
:
How often do you
expect the payment,
such as weekly,
fortnightly, monthly,
one-off.
The types of income
you need to include
here are listed on
page 12.
Do you expect to get income or other payments in the next 52 weeks?
No Yes
Please write the details below. Tell us the before-tax amounts
Where will the payment
come from?
Payment made to? How often do you
expect the payment?You Jointly with partner
$ $
$ $
$ $
$ $
$ $
Are you
involved
in a trust?
ATTACHMENT FOR Q32
:
You’ll need to show us
trust documents, such
as the trust deed, deed
of debt, gift statements,
accounts.
Are you involved in a trust, or have you ever been involved in a trust?
‘Involved’ means one or more of the following:
• you’ve set up a trust, usually by making a gift of assets or property
• you’ve gifted or sold assets to a trust
• you make decisions about managing a trust
• you benefit from a trust, for example, by receiving income such as trust distributions.
No Yes
Please write the name of the trust
Name of trust
30
31
32
Page 14 R31 – APR 2020
Tell us
about
your assets
ATTACHMENT FOR Q33
:
You may be asked to
provide proof of your
assets and their value.
Do you or your partner have any of the following cash assets?
Money in bank or other savings No Yes
Bonus Bonds, shares, debentures or stocks No Yes
Money lent to other people or organisations No Yes
Other cash assets No Yes
If you answered ‘yes’ to any of the assets listed above, please write the
details below.
Type of asset You Your partner Jointly owned
$ $ $
$ $ $
$ $ $
$ $ $
HOW TO ANSWER Q35
:
Examples of property
you do not live in include,
land, holiday homes,
bach/crib, investment
properties.
Do you or your partner have any of the following non-cash assets?
Property you don’t live in No Yes
Boat, caravan or motorhome No Yes
Other No Yes
ATTACHMENT FOR Q36
:
You may be asked to
provide proof of these
details.
If you answered ‘yes’ to any of the non-cash assets listed above, please write
the details below.
Type of asset How much is it worth?
How much do you
owe on it?
$ $
$ $
$ $
33
34
35
36
Page 15 R31 – APR 2020
Including a partner
obligations and privacy form
Both the applicant and partner need to read this section.
This part of the form:
• lists the change of circumstances obligations for the client
• lists the full obligations for the partner
• explains what will happen if obligations are not met
• explains how we protect the information given to us, and what we can do with it.
Clients including their partners will be aware of their full obligations, which have not changed.
Obligations Applies to:
These are what you have to do to receive payments from Work and Income. If you are a partner you have full-
time work obligations if youare:
• 18 or over and have no dependent children, or
• 20 or over and have no dependent children under 14 years old (including any child you get Orphan’s Benefit
or Unsupported Child’s Benefit for).
People in other situations may have part-time work obligations, work preparation obligations, or youth activity
obligations, depending on their circumstances. These obligations are explained in the following sections.
Please read all the obligations in each section because they could apply to you if your circumstances change.
1. Change of circumstances
I must tell Work and Income or my Contracted Service Provider (where I have one assigned to me)
immediately if either my partner or I:
• have a change in work situation (such as starting part-time, casual or full-time work, whether paid or unpaid)
• become self-employed/start to run a business
• have changes to my/our income or financial circumstances
• intend to travel overseas
• start/finish part-time or full-time study
• have changes to personal details (such as name, address, contact details or bank account number)
• have changes to my/our living situation (such as marriage or separation, starting or ending a civil union,
starting or ending a de facto relationship with someone, change in the number of children supported,
change in accommodation costs)
• are imprisoned/held in custody on remand
• are admitted to or discharged from hospital
• have been granted an overseas pension
• have any other change that may affect my/our benefit entitlement or rate.
Client and partner
2. Full-time work obligations
I understand that while I’m getting this benefit, I have the following full-time work obligations:
• be available for and take reasonable steps to get a suitable job
• take any offer of suitable full-time, part-time or temporary work, or work that is seasonal or subsidised
• attend and take part in any suitable job interviews Work and Income ask me to
• take and pass any drug test potential employers or training providers require
• attend and take part in interviews with Work and Income as required
• work with Work and Income to plan how I’ll find a suitable job
• take part in any other activities that Work and Income refer me to, such as attend any job training courses,
seminars, work experience or work assessments (including rehabilitation, but not medical treatment) that
will improve my work readiness or help me get work
• let Work and Income know how I’m meeting my work obligations as often as Work and Income
reasonablyrequires.
Partner
Full-time means you’ll
generally be expected
to look for work of at
least 30 hours a week.
Page 16 R31 – APR 2020
Obligations Applies to:
3. Part-time work obligations
I understand that if I am 20 years or older and my youngest child (including any child I get Orphan’s or
Unsupported Child’s Benefit for) is aged between three and 13 years, I’ll have the following part-time
work obligations:
• be available for and take reasonable steps to get a suitable part-time job
• take any offer of suitable part-time or temporary work, or work that is seasonal or subsidised
• attend and take part in any suitable job interviews Work and Income ask me to
• take and pass any drug test potential employers or training providers require
• attend and take part in interviews with Work and Income as required
• work with Work and Income to plan how I’ll find a suitable job
• take part in any other activities that Work and Income refer me to, such as attend any job training courses,
seminars, work experience or work assessments (including rehabilitation, but not medical treatment) that
will improve my work readiness or help me get work
• let Work and Income know how I’m meeting my work obligations as often as Work and Income
reasonablyrequires.
Partner
Part-time means you’ll
generally be expected
to look for work of at
least 20 hours a week.
4. Work preparation obligations
I understand that if I am 20 years or older and my youngest child (including any child I get Orphan’s or
Unsupported Child’s Benefit for) is under three years of age, I’ll have the following work preparation
obligations:
• take reasonable steps to prepare and plan for work
• attend and take part in work preparation interviews, where Work and Income ask me to
• attend and take part in work related activities or programmes such as a work assessment, a programme or
seminar to increase particular skills or enhance motivation where Work and Income ask me to
• attend and take part in any other activity that Work and Income require me to (including rehabilitation but
not medical treatment, voluntary work or activity in the community).
Partner
5. Work ability assessment
Where I’ve been asked to I’ll have an obligation to attend and participate in a work ability assessment.
Partner
6. Working with a Contracted Service Provider
Where I’ve been asked to work with a Contracted Service Provider I’ll have an obligation to co-operate
with them and to:
• attend and participate in any interview with them
• report to them on how I’m meeting my obligations
• complete assessments with them.
Partner
7. Obligations for parents and caregivers with dependent children
I understand that while I’m getting this benefit I’ll be expected to take reasonable steps to meet social
obligations as a parent or a caregiver. These are to ensure my dependent children (including any child I
get Orphan’s or Unsupported Child’s Benefit for) are:
• enrolled with a general practitioner (GP) or a medical practice that is part of a Primary Health Organisation
(PHO)
• enrolled in and attending one of the following from the age of three until they start school:
– an approved early childhood education programme or
– Te Aho o Te Kura Pounamu – The Correspondence School or
– another approved parenting and early childhood home education programme
• up to date with core Well Child/Tamariki Ora checks if aged under five
• enrolled in and attending school from the age of five or six (depending on when they start school).
I understand that I may be required to meet with Work and Income to discuss how I’m meeting my obligations
as a parent or a caregiver.
Partner
Page 17R31 – APR 2020
Obligations Applies to:
8. Youth activity obligations
I understand that if I am aged 16-17 years without children and I am a partner of a main beneficiary I will
have the following activity obligations:
• be enrolled in and attending, or be available for a full-time course of secondary school or tertiary education or approved training or
work-based learning leading to:
– NCEA Level 2 or
– an equivalent qualification or
– a higher qualification
• when asked, participate in and complete an approved budgeting programme
• when asked, report to Work and Income or my Youth Service Provider (where I have one assigned to me) on how I am meeting my
activity obligations
• when asked, attend and participate in regular budgeting discussions with Work and Income or my Youth Service Provider (where I have
one assigned to me)
• when asked, attend and participate in any interview with Work and Income or my Youth Service Provider (where I have one assigned
tome)
• when asked, provide within 20 working days, Work and Income or my Youth Service provider (where I have one assigned to me) with
details of my accommodation costs and service costs such as electricity and telephone, lawful debts and liabilities
• co-operate with Work and Income or my Youth Service provider to manage the spending of my benefit, and:
– attend and be involved in regular budgeting discussions with Work and Income or my Youth Service provider
– at these discussions or when asked, provide details on:
> accommodation costs and service costs such as electricity and telephone
> lawful debts and liabilities
> how I spend any in-hand allowance and money credited to my payment card or any other device.
I also understand when I turn 18 the above obligations may continue to apply depending on my circumstances.
I understand that if I am aged 16-19 years, I am a partner of a main beneficiary and have one or more dependent children, I will
have the following activity obligations:
• when asked, participate in and complete an approved budgeting programme
• when asked, participate in an approved parenting education programme
• enrol my children:
– with a Primary Health Organisation, where local provider capacity allows
– under the age of five years, with a WellChild/Tamariki Ora provider and keep up to date with their visits
• ensure my children are attending an Early Childhood Education Programme or other suitable childcare, while I am participating in
education, training, work-based learning or part-time work
• when asked and in the manner reasonably required, report to Work and Income or my Youth Service Provider (where I have one
assigned to me) on how I am meeting my obligations
• when asked, attend and participate in regular budgeting discussions with Work and Income or my Youth Service Provider (where I have
one assigned to me)
• when asked, attend and participate in any interview with Work and Income or my Youth Service Provider (where I have one assigned
tome).
I understand that when my youngest dependent child is 12 months of age or over (or is over
six months of age and a suitable place becomes available in a Teen Parent Unit) and there are no special circumstances, or I am
not the primary caregiver, I will also have the following activity obligations:
• be enrolled in and satisfactorily undertaking, or be available for a full-time course of secondary school or tertiary education or
approved training or work-based learning leading to:
– NCEA Level 2 or
– an equivalent qualification or
– a higher qualification.
• when asked, provide within 20 working days, Work and Income or my Youth Service provider (where I have one assigned to me) with
details of my accommodation costs and service costs such as electricity and telephone, lawful debts and liabilities
• co-operate with Work and Income or my Youth Service provider to manage the spending of my benefit, and:
– attend and be involved in regular budgeting discussions with Work and Income or my Youth Service provider
– at these discussions or when asked, provide details on:
> accommodation costs and service costs such as electricity and telephone
> lawful debts and liabilities
> how I spend any in-hand allowance and money credited to my payment card or any other device
I also understand when I turn 20 the above obligations may continue to apply depending on my circumstances.
9. Temporary Additional Support
I understand that if I receive Temporary Additional Support, my partner and I must take all necessary steps
to get other assistance towards costs and take reasonable steps to increase my income and reduce costs
wherepossible.
Partner
Client and partner
Page 18 R31 – APR 2020
What happens if you do not meet your obligations
Not telling us about changes in your circumstances
I understand that if I do not tell Work and Income about changes in my life that might affect my benefit entitlement, or rate, that:
• my benefit may be reviewed and cancelled and
• I may have to pay back the total amount of any overpayment that I have received and
• Work and Income may impose a penalty (up to three times the value of the overpayment) or
• I may be prosecuted and fined and/or imprisoned.
Not meeting obligations that apply to your situation
I understand that I must meet these obligations and that:
• The first and second time I don’t meet my obligations, without a good and sufficient reason, my benefit will be reduced
by 50% or stopped. I understand that my benefit will increase or restart if I undertake the activity I failed to do.
• The third time I don’t meet my obligations, without a good and sufficient reason, my benefit will be reduced by 50%
or stopped, for 13 weeks. If my benefit has been reduced or stopped, and I agree to take part in an approved activity
for at least six weeks and I’m still entitled to my benefit, it will be increased or restarted.
• When my benefit is reduced or stopped this may affect my entitlement to any incentive payments or supplementary assistance I am
receiving.
• If I act in a way that is inconsistent with the purpose for which any incentive payment is paid, the incentive payment may be cancelled.
• If my benefit is stopped and restarted again, I may have to re-earn my incentive payments.
Not meeting obligations that apply to your situation if you are subject to money-management
I understand that I must meet these obligations and that:
• The first and second time I don’t meet my obligations, without a good and sufficient reason, my in-hand allowance will be stopped. I
understand that my benefit will increase or restart if I undertake the activity I failed to do.
• The third time I don’t meet my obligations, without a good and sufficient reason, my benefit will be reduced by 50% or stopped, for
13 weeks. If my benefit has been reduced or stopped, and I agree to take part in an approved activity for at least six weeks and I’m still
entitled to my benefit, it will be increased or restarted.
• When my benefit is reduced or stopped this may affect my entitlement to any incentive payments or supplementary assistance I am
receiving.
• If I act in a way that is inconsistent with the purpose for which any incentive payment is paid, the incentive payment may be cancelled
• If my benefit is stopped and restarted again, I may have to re-earn my incentive payments.
Not meeting your obligation to take any offer of suitable work
I understand that if I fail my work obligation to take any offer of suitable work, including temporary work, or work that
is seasonal or subsidised, without a good and sufficient reason, that my benefit will be reduced by 50% or stopped,
for 13 weeks. If my benefit has been reduced or stopped, and I agree to take part in an approved activity for at least
six weeks and I’m still entitled to my benefit, it will be increased or restarted.
Not meeting your obligations to take and pass drug tests
I understand that if I fail my work obligation to take and pass a drug test when required by a potential employer or training provider,
without a good and sufficient reason, that:
• the first time I do this, I will have to agree to stop using drugs so that I can pass a drug test
• the second time I do this, I will have to agree to take and pass a drug test within 25 working days.
I understand that if I don’t take and pass a drug test within 25 working days my benefit will be reduced by 50%
or stopped, for 13 weeks. If my benefit has been reduced or stopped, and I agree to take part in an approved activity
for at least six weeks and I’m still entitled to my benefit, it will be increased or restarted.
I understand that if I fail a pre-employment drug test with a potential employer I will need to pay for the test from my benefit.
I also understand that if I have to take and pass a drug test within 25 working days I will need to pay for the test.
I understand that if I have failed other obligations in the last 12 months the consequences of a first or second failed drug test
may be more serious than those described above.
Not telling us if you plan to travel overseas
I understand that if I intend to travel overseas and don’t let Work and Income know before I leave New Zealand,
my benefit will be stopped the day after I leave New Zealand.
You have the right to review or dispute any decision to reduce or stop your benefit.
Page 19R31 – APR 2020
Privacy Statement
The Ministry of Social Development includes Work and Income, MSD Housing Assessment, Senior Services, StudyLink and
other service lines. The legislation administered by the Ministry of Social Development allows us to check the information
that you give us. This may happen when you apply for assistance and at any time after that. The Privacy Act 1993 requires
us to tell you why we collect the information and what we will do with it.
Why we collect information
The information you give us is collected under the authority of the legislation administered by the Ministry of Social Development
and will be held by the Ministry of Social Development.
The information is collected for the purposes of the legislation administered by the Ministry of Social Development including:
• granting benefits and other assistance under the Social Security Act 2018
• delivering superannuation services under the New Zealand Superannuation and Retirement Income Act 2001
• delivering assistance under the Veterans’ Support Act 2014
• providing services under the Residential Care and Disability Support Services Act 2018
• statistical and research purposes
• providing advice to Government
• providing support and services for you and your family
• providing education related services
• care and protection needs of children
• assessing eligibility for social housing and calculating income-related rents under the Housing Restructuring and Tenancy Matters Act 1992
• assessing whether you and/or your partner may be entitled to an overseas pension, benefit or allowance.
You are not required to give the Ministry of Social Development information, but if you do not give us all the information we ask for,
your application for benefits or pensions and other assistance may be declined.
We may contact health practitioners
The Ministry of Social Development may contact health practitioners to check any health related information you give us.
We may use information for public housing
Information you give us when you apply for assistance, and at any time after that, may also be used for public housing purposes under the
Housing Restructuring and Tenancy Matters Act 1992, including reviewing your eligibility for social housing or your income-related rent.
Public housing is subsidised housing available to people in the greatest need of housing for the duration of their need. It is provided by
Kāinga Ora and approved community housing providers.
We may compare the information you give us with information held by other agencies
The information you give us may be compared with information held by other agencies such as Inland Revenue, the Ministry of Justice,
Department of Corrections, New Zealand Customs Service, Department of Internal Affairs, Accident Compensation Corporation, Kāinga Ora,
Ministry of Health and Immigration New Zealand. It may also be compared with social security information (for example, pension or benefit
information) held by other governments (including Australia , Malta and the Netherlands).
We may share information with Inland Revenue
Under the Tax Administration Act 1994, if you have dependent children, the information you give us may be shared with Inland Revenue
for the purpose of administering Working for Families Tax Credits. Inland Revenue may also:
• use the information for the purposes of child support, student loans and taxation
• disclose it to the Ministry of Business, Innovation, and Employment, Statistics New Zealand, the Ministry of Justice, the Accident
Compensation Corporation, and the Ministry of Education
• disclose your personal information to your partner.
We may give information to service providers, employers, public housing providers
and childcare providers
The Ministry of Social Development may:
• give employers information about you if you use our employment services
• share information with childcare centres to administer your entitlement to childcare assistance
• give information about you to the Tertiary Education Commission, Workbridge, training providers, career services or other agencies
that have a formal agreement to provide services on behalf of the Ministry of Social Development, if you use our employment services
• share information about you with public housing providers (such as Kāinga Ora) to administer your housing-related assistance.
We may use your information to give you a better service
Other information that you give us that is not required to assess your entitlement may be used to provide a better service to you.
You have the right to see and correct your information
Under the Privacy Act 1993 you have the right to ask to see all information we hold about you and to ask us to correct that information.
Page 20 R31 – APR 2020
Page 21R31 – APR 2020
Signature page
Client’s copy
By signing this form, you agree to meet your obligations.
Applicant
• I have had the obligations explained to me, I understand these, and have been given a copy of
these obligations.
• I have read (or had explained to me) and understood what will happen if I do not meet my obligations.
• I understand my responsibility to let Work and Income or my Contracted Service Provider (where I have one
assigned to me) know about any changes in my circumstances and what will happen if I do not do this.
• I have read (or had explained to me) and understood the Privacy Statement contained in this form.
• The information I have provided is true and complete.
Client’s name (print) Client’s signature Date
Day Month Year
Partner’s copy
Partner
• I have had the obligations explained to me, I understand these, and have been given a copy of
these obligations.
• I have read (or had explained to me) and understood what will happen if I do not meet my obligations.
• I understand my responsibility to let Work and Income or my Contracted Service Provider (where I have one
assigned to me) know about any changes in my circumstances and what will happen if I do not do this.
• I have read (or had explained to me) and understood the Privacy Statement contained in this form.
• The information I have provided is true and complete.
Partner’s name (print) Partner’s signature Date
Day Month Year
Page 22 R31 – APR 2020
If we find out later that any information you give us is not true, or that you knew information you
should have told us and did not tell us, we may stop paying your benefit. You might need to pay
money back, we may impose a penalty, and you could be prosecuted.
Please use the “What to Bring” checklists on pages 1 and 2 to help you make sure you bring all the
documents you need to your meeting with us.
If we find out later that any information you give us is not true, or that you knew information you
should have told us and did not tell us, we may stop paying your benefit. You might need to pay
money back, we may impose a penalty, and you could be prosecuted.
Please use the checklists on pages 1 and 2 to help you make sure you bring all the documents you need to
your meeting with us.
Page 23R31 – APR 2020
Signature page
Office copy
By signing this form, you agree to meet your obligations.
Client
• I have had the obligations explained to me, I understand these, and have been given a copy of
these obligations.
• I have read (or had explained to me) and understood what will happen if I do not meet my obligations.
• I understand my responsibility to let Work and Income or my Contracted Service Provider (where I have one
assigned to me) know about any changes in my circumstances and what will happen if I do not do this.
• I have read (or had explained to me) and understood the Privacy Statement contained in this form.
• The information I have provided is true and complete.
Client’s name (print) Client’s signature Date
Day Month Year
Partner
• I have had the obligations explained to me, I understand these, and have been given a copy of
these obligations.
• I have read (or had explained to me) and understood what will happen if I do not meet my obligations.
• I understand my responsibility to let Work and Income or my Contracted Service Provider (where I have one
assigned to me) know about any changes in my circumstances and what will happen if I do not do this.
• I have read (or had explained to me) and understood the Privacy Statement contained in this form.
• The information I have provided is true and complete.
Partner’s name (print) Partner’s signature Date
Day Month Year
If we find out later that any information you give us is not true, or that you knew information you
should have told us and did not tell us, we may stop paying your benefit. You might need to pay
money back, we may impose a penalty, and you could be prosecuted.
Page 24 R31 – APR 2020
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Including a partner form If you get a (Ministry of Social Development New Zealand)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document