Fillable estpac KiwiSaver Scheme Serious Illness Withdrawal Application form (Accident Compensation Corporation New Zealand)

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estpac KiwiSaver Scheme Serious Illness Withdrawal Application form (Accident Compensation Corporation New Zealand)

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W
estpac KiwiSaver Scheme Serious Illness
Withdrawal Application form
August 2021.
KiwiSaver is designed for your retirement, but there are some circumstances in which you can make an early withdrawal. One of
these is a withdrawal on the grounds of serious illness. The information below will help you understand if you qualify for this early
withdrawal, and how to apply.
How do I qualify?
You may qualify if you have an injury, illness or disability:
– that results in you being totally and permanently unable to engage in
work that you are suited to because of your experience, education or
training or a combination of those things; or
– that poses a serious and imminent risk of death
If you’re not sure whether you qualify, please call us on 0508 972 254,
(+64 9 375 9978 if you are calling from overseas) to discuss your situation
before sending us your application.
How do I apply?
To apply for a serious illness withdrawal, you will need to provide the
following:
– A completed serious illness withdrawal application form. All sections
must be completed and signed, including the statutory declaration
which must also be witnessed by a person authorised to take a statutory
declaration
– A completed medical practitioner’s declaration (attached at the bottom
of this form).
– A certified copy of your identification (e.g. a New Zealand passport or
current New Zealand driver licence).
– A certified copy of evidence of your address (e.g. a recent water or
electricity bill).
For a full list of acceptable identification and address verification documents,
please go to westpac.co.nz/AML
What is a “certified copy”?
A certified copy is a photocopy of an original document, on which an
authorised person (see section F of this form) has:
– written “I certify this to be a true copy of the original document” or
words to that effect (adding in the case of an identification document
the words “and that it represents the identity of [full name]”); and
– added their name and occupation, the date, their signature, their
registration number (or equivalent) and their contact phone number.
The certifier cannot be someone who is related to you, is your spouse or
partner, or lives at the same address.
How much can I withdraw?
If your application is approved, you can withdraw some or all of the available
balance in your Westpac KiwiSaver Scheme account. If your application is
approved and you choose to withdraw a partial amount, future withdrawal
requests will require further documentation and/or a new application.
How will I know if my application is approved?
Approval will generally take up to 5 working days after we obtain all the
required information and pass it to The New Zealand Guardian Trust Company
Limited (Supervisor). If your withdrawal request is approved your withdrawal
amount will be paid to the bank account you nominate on this form, generally
within 5 business days of the withdrawal request approval.
How can I find out the status of my application?
For an update on your application, please call us on 0508 972 254 from
8.30am to 5pm, Monday to Friday (or +64 9 375 9978 if you are calling from
overseas).
A. Your details
Mr Mrs Miss Ms Other (please specify) Date of birth DD
/
MM
/
YYYY
Name
FIRST MIDDLE LAST
IRD number Westpac KiwiSaver Scheme member number
K S
Prescribed Investor Rate (PIR*) 10.5% 17.5% 28% *For help in determining your PIR go to ird.govt.nz/pir
Phone HOME MOBILE
Email
Home Address NUMBER & STREET SUBURB
TOWN/CITY POSTCODE
Postal Address (if different) NUMBER & STREET SUBURB
TOWN/CITY POSTCODE
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B. Withdrawal
details
I would like to make a (please tick)
Withdrawal of all my full available balance
If you choose to withdraw your full available balance, our written confirmation that your withdrawal request is
approved will include notice to you that your account has been closed and you are no longer a Westpac KiwiSaver
Scheme member
or
Partial withdrawal
1
of $
1
If you are approved for a partial withdrawal, future requests will require further documentation or a new application.
If you are making a partial withdrawal and are invested in two or more funds, the amount specified above will be withdrawn
proportionately across each fund that you are invested in.
If you would like to give us specific partial withdrawal instructions based on your chosen mix of funds, please specify below the
dollar amount you would like to withdraw from each fund:
C. Payment
details
Please provide us a New Zealand bank account that is either solely or jointly held in your name (i.e. not a trust account or business
account). If your withdrawal request is approved, the amount requested in section B above will be paid to your nominated
account. If the bank account below is not a Westpac New Zealand bank account, you will need to supply a certified copy or an
original of a bank statement/deposit slip.
Account holder’s name
Account Number
Bank Branch Account Number Suffix
D. Medical
declaration
Please indicate the type of injury, illness or disability you are suffering from:
This results in me being totally and permanently unable to engage in work for which I am suited by reason of
experience, education or training (or any combination of those things).
Please also include your job title and description of the occupation(s) you have held for the last 3 years below, including
your most recent occupation prior to the injury, illness or disability.
This poses a serious and imminent risk of death.
E. Privacy
statement
The personal information which you provide in (or in connection with) this form will be held securely by BT Funds Management
(NZ) Limited (Manager) and/or The New Zealand Guardian Trust Company Limited (Supervisor), at the address of the Manager,
and may be disclosed to Westpac Banking Corporation ABN 33 007 457 141 (Westpac), Westpac New Zealand Limited (Westpac
NZ) and any other entity that is involved in the administration and management of the Westpac KiwiSaver Scheme (including
Inland Revenue and any regulatory body). You will have the right to access and correct this information subject to the provisions
of the Privacy Act 2020. This information will be used now and in the future to provide you with information on the full range
of financial services offered by Westpac NZ and/or any entity within the Westpac Group, and may be used to update any other
information about you held by any member of the Westpac Group.
F. Statutory
declaration
Please do not complete the section below in advance. It must be completed and signed in front of a Justice of the Peace, a
solicitor, a notary public or another person authorised to take a statutory declaration. Please note that Westpac staff cannot
complete this statutory declaration.
I, FULL NAME
of, ADDRESS
OCCUPATION
Solemnly and sincerely declare that
– the information I have provided in this Westpac KiwiSaver Scheme Serious Illness Withdrawal Application Form (and any included materials)
is true and correct.
– I have read and understood the privacy statement set out in section E of this form.
– I understand that approval of this application is at the discretion of the Supervisor of the Westpac KiwiSaver Scheme, The New Zealand
Guardian Trust Company Limited.
– I understand that the Supervisor will not be able to complete its assessment of this application if the information given in this form is
incomplete or incorrect.
– I understand that the available withdrawal value will be based upon the unit price(s) applying on the business day my request is processed
and that fees, taxes and expenses may be deducted.
– I understand that the Manager (BT Funds Management (NZ) Limited) and/or the Supervisor may request additional information from me/the
medical practitioner involved in this application to gain clarity on my condition if required, and I consent to the medical practitioner providing
my personal information to the Manager and/or the Supervisor for that purpose.
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F. Statutory
declaration
(continued)
– I agree that if I withdraw the total available balance in my Westpac KiwiSaver Scheme account then my membership will end, the Manager will
close my account and each of Westpac, Westpac NZ, the Manager and the Supervisor will be released from all claims that have been made
or may be made by me or on my behalf in relation to the Westpac KiwiSaver Scheme.
– I understand that for any period(s) during my KiwiSaver membership when New Zealand was not my principal place of residence, any
government contributions claimed on my behalf will be deducted from my withdrawal amount and returned to Inland Revenue.
– to the best of my knowledge, during my KiwiSaver membership New Zealand has been my principal place of residence except for the period(s)
noted below (if relevant). The periods during my KiwiSaver membership when New Zealand was not my principal place of residence are noted
below (note these do not include overseas holidays where you remained a New Zealand resident)
:
Start Date End Date
DD / MM / YYYY DD / MM / YYYY
DD / MM / YYYY DD / MM / YYYY
DD / MM / YYYY DD / MM / YYYY
DD / MM / YYYY DD / MM / YYYY
DD / MM / YYYY DD / MM / YYYY
DD / MM / YYYY DD / MM / YYYY
And I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957.
Your signature
Declared at PLACE
This day of 20
Before me (JP, solicitor, notary public, a Registrar or Deputy Registrar of the District Court or the High Court, or other person
authorised to take a Statutory Declaration in accordance with the Oaths and Declarations Act 1957):
NAME OF WITNESS
DECLARED AT
OCCUPATION
Signature of Witness
Date
DD
/
MM
/
YYYY
STAMP
G. Your checklist Please ensure that you provide us with all of the following:
correctly completed and signed application form
your original statutory declaration signed by you, and witnessed by a person authorised to take statutory declarations
a signed medical practitioner’s declaration (attached to this form)
a certified copy of evidence of your address. Evidence of address must not be a Westpac issued document and can
include a rates, power or phone bill
a certified copy of your identification. This is usually by way of either a certified copy of a New Zealand passport or New
Zealand driver licence
If the bank account you have provided is not a Westpac New Zealand bank account, you must also provide a
certified copy or an original of a bank statement/deposit slip.
For a full list of acceptable documents, please go to westpac.co.nz/AML
H. Submit your
application
Please return the completed form, together with all supporting documents, to:
Westpac KiwiSaver Scheme Or courier it to: Westpac KiwiSaver Scheme
PO Box 934 Wealth Operations, Level 4 CS
Shortland Street Westpac on Takutai Square
Auckland 1140. 53 Galway Street
Auckland, New Zealand.
Or visit your nearest Westpac branch.
Please call us on 0508 972 254 from 8.30am to 5pm, Monday to Friday (or +64 9 375 9978 if you are calling from overseas) if you
need help completing this form. Alternatively, you can email us at kiwisaverhelp@westpac.co.nz.
Westpac New Zealand Limited
JN14705-3 07-21
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Medical Practitioner’s declaration
(to be completed by a Medical Practitioner)
A. Patient details
Mr Mrs Miss Ms Other (please specify)
Name FIRST MIDDLE LAST
Postal Address NUMBER & STREET SUBURB
TOWN/CITY POSTCODE
B. Medical
Practitioner’s
details
I, NAME
Registration number
of
WORKPLACE TOWNCITY
Business phone HOME MOBILE
Email
STAMP
Certify that:
1. I am a registered Medical Practitioner with the Medical Council of New Zealand.
2. The above-named is a patient of mine and I have recently given them a full medical examination. The patient is suffering from
the following injury, illness or disability:
3. In my opinion, the patient’s injury, illness or disability:
Results in them being totally and permanently unable to engage in work they are suited for because of experience,
education or training, or any combination of these; or
Poses a serious and imminent risk of death;
or
In my opinion, the patient does not meet either of the criteria above.
I form this opinion based on the below information (give a brief description of the patient’s condition, including date of diagnosis
and treatment in place). Please attach any relevant supporting information or documentation.
Signature of Medical Practitioner
Date
DD
/
MM
/
YYYY
Please ensure you attach this confidential Medical Practitioner’s declaration to the rest of your application.
Westpac New Zealand Limited
JN14705-3 07-21
Important: Please ensure you attach this Medical Practitioner’s
declaration to the rest of your application.
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estpac KiwiSaver Scheme Serious Illness Withdrawal Application form (Accident Compensation Corporation New Zealand)

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Completed 17 November 2021

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