Ministry of Social Development - Confirming your Circumstances

CLIENT NUMBER
393-537-938

Scott Anthony Hughes

113 Methuen Road
New Windsor Please return this form to:
Auckland 0600
Centralised Services Ellerslie Unit
PO Box 11593
Ellerslie, Auckland 1542

Please fill out all the questions on this form as they apply to you for the period 15 August 2016 to 13 August 2017.

If any of the questions don't apply to you, write "nil".

Getting the information to us on time

You'll need to get your completed form to us by 04 August 2017 or your payments may be delayed.

If you need any help completing this form, call us as soon as possible on 0800 559 009 or if you're aged 65 or over, call us on
0800 552 002 so we can help.

Address 1. Has your address changed?

Give your house number, No Go to Question 2. Yes Give your new address below:
street, suburb and your
town or city.

2. Who do you live with?

First Name Surname Relationship to you

3. What is your contact telephone number?

Partner 4. Do you have a partner?

A partner is your spouse No - Are you: Single Living apart / separated Divorced
(husband or wife), your civil
union partner, or a person Widowed Civil Union dissolved
of the same or opposite sex
with whom you have a
de facto relationship Yes - Are you: Married In a Civil Union In a relationship

Please contact us if your relationship status has changed

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 CLIENT NUMBER
393-537-938

Supported 5. You have been receiving Supported Living Payment because you
have someone in your care. Has this person left your care?
Living
Payment
You are receiving No Please state the full Yes Please state the date they left your care
Supported Living Payment name of the person
because you are caring for being cared for.
someone at home who Full name of person being cared for Date left care
would otherwise require
hospital care, or a similar / /
level of care.

Childcare 6. If you are working, do you pay for childcare?

Please complete this No Go to Question 9. Yes Please answer the questions below:
section only if you are
receiving the Domestic 7. How much are you paying each week? $
Purposes Benefit, Widows
Benefit or Emergency
Maintenance Allowance.

Give the name of the 8. Who do you pay for the care of your child?
Organisation or individual
that is caring for your child.

Working 9. Are you and/or your partner (if you have one) in employment?

Paid employment includes No Go to Question 11 Yes Please give details of who you are working for below
employment for which you
receive non monetary You
benefits e.g. free board Your partner

Give gross (before tax is 10. How much is your and/or your partner’s gross weekly wage?
taken out) amount of wages
and the value of any non You $ Your partner $
monetary benefits received
e.g. free board
11. Have you or your partner arranged to start work?
• You may be required to No Go to Question 12 Yes Please give details below:
provide verification

Date you start Date your partner starts

work work
Day Month Year Day Month Year

Give the name, telephone Name, address and telephone number of employer:
number and address of the
firm or person. You
Your partner

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 CLIENT NUMBER
393-537-938

Other Income
Examples of income from
other sources:
• Wages or Salary
• Termination pay 12. Do you or your partner (if you have one) expect to get money (other than from NZ
• Redundancy pay
• Accident compensation (e.g. Superannuation or benefit) over the next 52 weeks?
ACC)
• Income Insurance (replacement / No Go to Question 13. Yes Please give details below:
protection)
• Farm or business income Where will it come from? You Your partner Jointly
• Payments from self-employment
or contract work $ $ $
• Interest from savings,
investments or bonds $ $ $
• Dividends from shares, unit trusts
or managed funds $ $ $
• Income from rents
• Payments from Boarders or
flatmates $ $ $
• Child Support payments
• Other Income for a child $ $ $
• Maintenance payments
• Payments from a former partner $ $ $
• Student Allowance, scholarship or
Student Loan living costs $ $ $
payments
• Overseas pension, benefit or $ $ $
allowance payments
• Other superannuation or $ $ $
retirement scheme income
(government or private)
• Income from an estate, if you
$ $ $
have inherited any money
• Income from trusts $ $ $
• Other
$ $ $

Please give gross (before

tax) income.

• You may be required to

provide verification

Assets 13. Do you or your partner (if you have one) have any cash assets?
Examples of cash assets: No Go to Question 14. Yes Please give details below:
• money in a bank or savings Type of Asset You Your partner Jointly owned
organisation
• money lent to other people or $ $ $
organisations
• money in Bonus Bonds, $ $ $
shares, debentures or
government stock $ $ $

Examples of non-cash 14. Do you or your partner (if you have one) have any non cash assets?
assets:
• leisure boats No Go to Question 15. Yes Please give details below:
• caravans
• land or buildings other than Type of Asset You Your partner Jointly owned
your home, e.g. holiday homes
$ $ $
$ $ $
$ $ $
You may be required to 15. Do you or your partner (if you have one) have a family trust?
show proof of these details.
No Go to next section. Yes Please give details below:
Details You Your partner Jointly owned

$ $ $
$ $ $
$ $ $

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 CLIENT NUMBER
393-537-938

Disability You have been receiving a Disability Allowance of $7.60 per week for:
Allowance YOURSELF
Details
16. Have the following expenses you pay because of your disability changed or stopped?
Yes No
Expense/Item Amount How often expense is paid (please tick)
If you answer ’YES’ to any
of the expense/items Medical Fees $ 335.00 ANNUALLY
please advise details in
Question 17 Prescription charges $ 60.00 ANNUALLY

Yes Go to Question 17. No Go to Question 18.

You must provide 17. Please list any changes to your expenses that are a result of your disability
invoices, receipts, Changed Stopped
quotes or printouts for Expense/Item Amount How often expense is paid (please tick)
any new or increased
costs before they can
be considered as an
ongoing cost for
Disability Allowance.
You do not have to
provide any proof of
costs that have gone
down

Examples of expenses: 18. Do you have any new expenses that are a result of your disability?

• medical costs
• gardening No Go to Next Section. Yes Please give details below:
• transport How often expense is paid
• medical alarms Expense/Item Amount (daily, weekly, etc.)?

Statement The information I have given on the Ministry of Social Development -

Confirming your Circumstances form is true and I have not left anything out.
This information is required
under the Social Security Please sign here
Act 1964.

Day Month Year

Office Use Decision

Only Continue AT $ Per week FROM TO

Cancel FROM

Letter Reference Processing Officer

Day Month Year

Team Coach
Day Month Year

Bring up File

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