106425 ISSBOA3 0505 22/12/05 4:16 PM Page 1
Please Sign Here
Information Release Form –
Australia
Authority to release information
Agreement on Social Security between Australia and New Zealand
ISSBOA3
Statement
Authority for Work and Income to give information to Centrelink International Services in Australia
I authorise Work and Income to give Centrelink International Services in Australia any information that is required to determine
my entitlement to a pension from the Government of Australia under the Social Security Agreement which NewZealand has
entered into with Australia.
I understand that I have a right of access to the information given to Centrelink under the New Zealand Privacy Act 1993.
The Privacy Act 1993 requires us to inform you that the information that you have authorised Work and Income to give to
Centrelink is being supplied under the authority of the Agreement on Social Security between New Zealand and Australia.
The information is required to assess your entitlement to an Australian pension, benefit or allowance and will be used for
the functions and purposes of the overseas institution(s).
You have the right of access to the information about yourself sent to Centrelink and to request corrections of this information.
Please read this statement carefully and sign below.
Authority
Authority for Centrelink International Services in Australia to give information to Work and Income
I authorise Centrelink International Services in Australia to give Work and Income any information that is required to
determine my entitlement to a New Zealand benefit or pension under the Social Security Agreement between NewZealand
and Australia and the legislation of New Zealand.
I understand that I have a right of access to the information given to Work and Income under the New Zealand Privacy
Act1993.
The Privacy Act 1993 requires us to inform you that the information that you have consented to Work and Income obtaining
is being obtained under the Social Security Agreement between New Zealand and Australia.
The information is required to assess your entitlement to a New Zealand pension, benefit or allowance and will be used
for the functions and purposes of Work and Income.
You have the right of access to the information held about yourself by Work and Income and to request corrections of
thisinformation.
Your name:
First name(s) Surname
Mrs Miss Ms Mr No title Other
Day Month Year
DatePlease sign here
Australian Customer Reference Number:
Work and Income Client Number:
Suburb Town/City Post code
House number and street
Your address:
or signature of attorney or other authorised agent of client
Please complete and return to International Services, Work and Income, Ministry of Social Development, PO Box 27 178, Wellington
