Fillable Repayment Financial Circumstances Form (Ministry of Social Development New Zealand)

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Repayment Financial Circumstances Form (Ministry of Social Development New Zealand)

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1D003W – MAY 2012
Repayment Financial Circumstances Form
Please read this
before you start
CLIENT NUMBER
Personal details
Q4 note: Please give your house
number, street, suburb, and town
or city.
A house number could include:
street number •
re number •
RAPID number •
emergency services number. •
Q5 note: Mailing address includes:
street address •
postal box (PO Box) •
rural delivery details •
C/O address. •
Q2 note: Give any other names that
you use now or have used in the
past (including your maiden name).
1. What is your name?
First name(s) Surname or family name
2. Are you known by or have you used any other names?
No Yes
u
Please give details below:
1.
2.
3. What is your date of birth?
Day Month Year
4. Where do you live?
Flat/house no. Street name
Suburb City
5. What is your mailing address (if different from above)?
If you live at a rural address please include your rural delivery details here:
If you are unable to afford to pay the standard repayment rate on the amount you owe us,
please use this form to provide us with more information about the amount you may be able
to repay. If we accept your proposal, we will conrm the arrangement with you.
After completing this form, please send to:
Collections Unit
PO Box 19236
Hamilton 3244
Or email to collections_unit@msd.govt.nz
Why we are collecting
this information
Because you owe money to the Ministry of Social Development (MSD), we need to collect this
information to determine your nancial circumstances.
The Privacy Act requires us to tell you that:
– the information you give is is collected under the authority of the legislation administered
by MSD
– the information will be held by MSD
– you can contact MSD to access and correct any personal information we hold about you.
You are not required to give us information, but if you do not give us all the information
we ask for we can issue notices under Section 11 of the Social Security Act 1964 to other
people requiring them to provide the information. They are legally required to give it and
there may be consequences if they don’t (eg an application for a benet may be declined if
the information is required to determine eligibility for it).
In asking you for this information, we are following the Code of Conduct for Obtaining Informa-
tion under Section 11 of the Social Security Act 1964. If you want to see a copy of the Code, you
can ring MSD on 0800 558 008 or visit our website at:
www.msd.govt.nz/about-msd-and-our-work/about-msd/legislation/
D003W – MAY 20122
D003W – OCT 2010
Personal details
– continued
6. How can we contact you?
Work phone Home phone Mobile phone
Email Fax
7. Do you have dependent children in your care?
No Yes
u
If YES, how many?
8. Do you have a partner?
No Yes
Q8 note: A partner is your spouse
(husband or wife), your civil union
partner, or a person of the same or
opposite sex with whom you have
a de facto relationship.
9. Are you self-employed?
No Yes
u
Go to Question 16
10. Are you currently working?
No
u
Go to Question 16 Yes
11. What is the name of the business you work for?
12. Where is the business located?
Street number Street name
Suburb City
13. What is the postal address?
PO Box no. Suburb City
14. What is the name of your employer/payroll ofcer?
15. How can we contact your employer/payroll ofcer?
Work phone Fax Mobile phone
Email
Employment
D003W – OCT 2010
3D003W – MAY 2012
Assets
Q18 note: Examples of cash assets:
money in bank or savings •
organisation
money lent to other people or •
organisations
money in Bonus Bonds, shares, •
debentures or government stock.
Q19 note: Examples of non-cash
assets:
leisure boats •
caravans •
land or buildings other than your •
home, eg holiday homes.
You may be required to show proof
of these details.
18. Do you and/or your partner have any cash assets?
No Yes
u
Please provide details below:
Type of asset You Your partner Jointly owned
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
19. Do you and/or your partner have any non-cash assets?
No Yes
u
Please provide details below:
Type of asset Total value Money owing
$ $
$ $
$ $
$ $
$ $
Expenses
Q20 note: Examples of weekly costs
include:
groceries •
rent/board/mortgage •
transport/fuel •
child support payments •
weekly debt payments •
nes •
childcare/school costs •
superannuation scheme payments. •
You may be required to show proof
of these costs.
20. Do you and/or your partner have regular weekly costs?
No Yes
u
Please provide details below:
Type of costs How much
$
$
$
$
$
$
$
Total $
Income
Q17 note: Examples of income include:
wages or salary •
accident compensation •
farm or business income (include •
drawings)
self employment •
interest from savings or investments •
dividends from shares •
income from rents •
redundancy or termination type •
payments
Child Support •
maintenance payments •
income from boarders •
Student Allowance, scholarship or •
Student Loan living cost payments
any other income, eg family trusts, •
overseas payments
New Zealand Superannuation. •
Give gross (before tax) amount.
You may need to provide proof of
this income.
16. How much is your weekly wage after tax? $
17. Do you and/or your partner have any other income?
No Yes
u
Please provide details below:
How often
Source (eg name of employer) You Your partner (eg weekly, fornightly etc)
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
0.00
D003W – MAY 20124
D003W – OCT 2010
Expenses – continued
Q21 note: Examples of monthly costs
include:
rent/board/mortgage •
power, gas, wood •
phone, cellphone, internet, etc •
pay television •
credit card and store card payments •
monthly debt payments including hire •
purchase, car, personal loans, etc
bank fees •
medical costs (eg, doctor, chemist, •
dentist, optician)
rental of appliances (eg, computer, TV, •
washing machine).
You may be required to show proof of
these costs.
Q22 note: Examples of yearly costs
include:
council and water rates •
insurance premiums •
vehicle costs (eg, registration, WOF) •
clothing and footwear •
household goods. •
You may be required to show proof of
these costs.
21. Do you and/or your partner have regular monthly costs?
No Yes
u
Please provide details below:
Type of costs How much
$
$
$
$
$
$
$
$
Total $
22. Do you and/or your partner have regular yearly costs?
No Yes
u
Please provide details below:
Type of costs How much
$
$
$
$
$
$
$
$
Total $
Liabilities
Q23 note: Examples of liabilities include:
unpaid bills •
store card balances •
credit card balances •
Child Support arrears •
Work and Income debt •
outstanding rent or Housing •
New Zealand debt
outstanding nes •
hire purchases •
mortgage •
bank/nance company loans. •
You may be required to show proof of
these costs.
23. Do you and/or your partner have any liabilities?
No Yes
u
Please provide details below:
Type of liability Final payment date Balance owing
/ / $
/ / $
/ / $
/ / $
/ / $
/ / $
/ / $
Total $
Insolvency
Q24–26 note: These are orders made
by the Ofcial Assignee. The orders
mean that your debt(s) are managed
by them in specic ways.
24. Are you and/or your partner under the No Asset Procedure?
No Yes
25. Do you and/or your partner have a Summary Instalment Order?
No Yes
26. Are you or your partner currently bankrupt?
No Yes
0.00
0.00
0.00
D003W – OCT 2010
5D003W – MAY 2012
Repayment details
Q27 note: You must make either a:
lump sum payment •
regular weekly, fortnightly or •
monthly payment, or
combination of both. •
27. How much can you afford to pay? $
28. How often will you pay?
Weekly Fortnightly Monthly
29. What will be the date of your rst payment?
Day Month Year
30. How will you pay?
Automatic payment Deduction from wages
Internet banking Cash/cheque at NZ Post
Benet deduction
31. Would you like any part of this payment credited to any amount your partner owes us?
No Yes
u
How much do you want to pay? $
u
What is your partner’s client number?
Supporting
information
32. Is there anything else we need to know to support your proposal?
No Yes
u
Please provide details below:
I conrm that:
The information I have supplied is true and complete.
I have reviewed my nancial situation and can afford these repayments.
I don’t have any money available to make the repayment in full.
Conrmation
A signature is not required if this
form is being sent by email.
Name (print) Client’s signature
Day Month Year
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Repayment Financial Circumstances Form (Ministry of Social Development New Zealand)

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Completed 11 February 2021

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