Fillable Seasonal Work Assistance application form (Ministry of Social Development New Zealand)

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Seasonal Work Assistance application form (Ministry of Social Development New Zealand)

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Country of origin: NEW-ZEALAND
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Page 1 M46W – DEC 2020
Seasonal Work Assistance
application form
Seasonal Work Assistance is temporary financial help for people who are doing seasonal work in horticulture
but can’t work because of bad weather.
To get this payment you need to have:
• stopped your benefit within the last 26 weeks, because you started working in a seasonal horticulture job
• lost wages from not being able to work because of bad weather.
Your employer may need to fill in part of this form.
This number can be found on your Community Services Card if you have one.
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
HOW TO ANSWER Q3
:
If you live in a rural
area, flat/house number
could include your RAPID
number, fire number,
emergency services
number.
Where do you live?
Flat/House number Street name
Suburb Town/City
HOW TO ANSWER Q4
:
Mailing address can
include a POBox, rural
delivery details, or C/O
address.
Is your mailing address different from where you live?
No Yes
Tell us your mailing address
HOW TO ANSWER Q5
:
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 ( )
Email
1
2
3
4
5
Page 2 M46W – DEC 2020
Have your bank account details changed since your benefit stopped?
No
Go to question 8
Yes
Go to question 7
ATTACHMENT FOR Q7
:
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
about
income in the
last week?
ATTACHMENT FOR Q8
:
Bring a copy of your
business accounts.
INFORMATION FOR Q8
:
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 week?
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
6
7
8
Page 3M46W – DEC 2020
Did you answer ‘Yes’ or ‘Jointly with partner’ to any of the sources of income
listed in question 8?
No Yes
Tell us the total before-tax amounts
Payment made to?
Where did the income come from? You Jointly with partner
$ $
$ $
$ $
$ $
$ $
HOW TO ANSWER Q10
:
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 week?
No Yes
Please tell us about the type of payment and its value
Type of payment Where did it come from? Its value
$
$
Tell us
about
your assets
ATTACHMENT FOR Q11
:
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
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
$ $ $
$ $ $
Signature
I am working full-time in seasonal horticulture work and I lost wages due to poor weather conditions.
I have answered all the questions that apply to me and my situation.
The information I have given you is true and complete.
I understand the things I need to do while I’m getting payments.
I will do what I need to do to meet my obligations.
I understand what you do with my personal information and how you protect my privacy.
Applicant’s name (print) Applicant’s signature Date
Day Month Year
9
10
11
12
Page 4 M46W – DEC 2020
Seasonal Work Assistance
employer confirmation
Please ask your employer to complete this section or talk with us about contacting your employer directly.
Appliant’s
details
What is full name of the employee you are completing this form for?
First and middle names
Surname or family name
Employer’s
details
What is the name of your company or organisation?
What is your company or organisation’s address?
Number Street name
Suburb Town/City
Work details
I confirm the following wage details for the applicant
Week ending
Day Month Year
Number of hours lost in the week
Estimate net wages lost in the week
$
What is the reason for the short week?
Employer’s
verification
Employer’s first and middle names Employer’s surname or family name
Date
Day Month Year
1
2
3
4
5
Page 5 M46W – DEC 2020
Collecting your information
We collect your personal information, so we can provide income support, NZ Super or Veteran’s Pension, Student
Allowance, or Loans and connect you with employment, education and housing services. We do this under various
Acts, which are all listed on our website at workandincome.govt.nz/privacy
• To help us do this, we collect information about your identity, your relevant history, and your eligibility for our services.
• We get this information directly from you, and we sometimes collect information about you from others, including other
government agencies.
• You can choose not to give us your personal information, but we might not be able to help you if you don’t.
Using your information
We use the information you give us to make decisions about the best way to help you.
• These decisions may be about:
– whether you’re eligible for our services
– running our operations and ensuring our services are effective
– the services we’ll provide in the future.
Sharing your information
Sometimes, we need to share your information outside our Ministry to reach our goal of helping NewZealanders
to be safe, strong, and independent.
• To do this, we may share your information with:
– prospective employers to help you find work
– contracted service providers that help us to help you
– health providers if we need your medical information to assess your eligibility
– other government agencies when we have an agreement with them
– some other governments if you may be eligible to get or are getting an overseas pension.
• We also share personal information when the law says we have to.
Respecting you and your information
We make sure we follow the Privacy Act to do what’s right when we use your information.
• We treat you and your information with respect, by acting responsibly and being ethical.
• We make sure any technology we use meets strict security standards so it keeps your information safe.
Get in touch if you have a question
You have a right to ask to see your personal information, and to ask for it to be corrected if it’s wrong.
• If you have a question or a complaint, please get in touch.
• You can find full details about what we do with personal information in our privacy notice at:
workandincome.govt.nz/privacy
How we protect your
privacy
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Seasonal Work Assistance application form (Ministry of Social Development New Zealand)

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Completed 11 February 2021

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