Name: Megan Sisley

SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

What you may be able to get

Based on your answers you may be able to get the following financial assistance:

• Supported Living Payment

A weekly payment which helps people who are severely limited in how much work they can do.

• Winter Energy Payment

A weekly payment which helps with the cost of heating over the winter months. People on a benefit or pension get
this automatically.

• Accommodation Supplement
A weekly payment which helps people with their rent, board or the cost of owning a home.

• Temporary Additional Support

A weekly payment which helps someone who can't meet their essential living costs from what they earn or from
other sources.

Other assistance
Everyone's situation is different. Please discuss your situation with us when you meet with us. We'll ensure that you get
all the assistance that you're entitled to from us. We may also be able to refer you to other agencies for other assistance.

Tell us about change

If your circumstances change you need to tell us straight away as it may affect the types or amount of assistance you
can get. If you don't, you could miss out on extra payments or end up with a debt to pay back.

Next steps

Please remember, you have 20 working days to complete this application from the date you started it or from when you
first contacted us, whichever comes first.

If there are additional things we need, you'll find these in your next steps in the 'current applications' screen in
MyMSD.

Page 1 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

Summary
Reason For Application
What is the reason for your application? : I'm a sole parent. My youngest child is under three
years old

Reason For Application Details

Is this the first time you have contacted us about Yes
this benefit application? :

Submission
Electronic Signature Received : Yes

Name and Contact Details

Title : Ms
First Name : Megan
Family Name : Sisley
Middle names : Brooke
Full Name is correct : Yes
Date of Birth : July 12, 1986
Gender : Female
Known by or other names used : No
Mobile Phone country code : 64
Mobile Phone prefix : 027
Mobile Phone Number : 9234573
Preferred phone contact : Mobile phone
Home email : megansisley@hotmail.com
Preferred email contact : Home email
Would you like to get email updates from us? : No
Contact you'd like us to try first : Email
Have you had any children in your care in the last No
52 weeks who are no longer dependent on you? :
Do you have a child or young person who needs No
constant care and attention for at least 12 months
because of a serious disability? :
If you qualify for any Family Tax Credit or Best No
Start Tax Credit do you want it paid with your
benefit? :
Have you served with the New Zealand Armed No
Forces? :

Page 2 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

Residential Address Details

Address Line 1 : 9 Whitaker Street
Suburb : Kihikihi
City : Te Awamutu
Country : New Zealand

Postal Address Details

Address Line 1 : 9 Whitaker Street
Suburb : Kihikihi
City : Te Awamutu
Country : New Zealand

Current or Past Benefit Details

Do you currently receive any type of assistance No
from Work and Income or StudyLink, or have a
Community Services Card? :
Have you ever received any type of assistance Yes
from Work and Income or StudyLink, or had a
Community Services Card? :
What is your client number? : 394700005

Accommodation Costs Details

Do you pay rent, board or have costs from owning Yes
a home? :
What type of accommodation cost(s) do you Rent
have? :
What is the total amount of rent paid each 500.00
week? :
How much of this total amount do you pay for 500.00
you and your family? :
Do you pay rent to Housing New Zealand? : No
Landlord's Name : Niki Ormsby
Landlord's Address : 7 Whitaker Street Kihikihi Te Awamutu 3800
Landlord's Phone : 027 532 4609
Do you pay water rates separately from your No
rent? :

Family Details
Do you currently receive either Family Tax Credit Yes
or Best Start Tax Credit from Inland Revenue? :

Page 3 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

Child Name and Contact Details

First Name : Lukas
Family Name : Evans
Date of Birth : February 27, 2014
Gender : Male
What is this child's relationship to you? : Child
Parent One : Me
Parent Two : Unknown
When did the child come into your care? : February 27, 2014

Child Name and Contact Details

First Name : Caleb
Family Name : Sisley -Harman
Middle names : William
Date of Birth : July 11, 2022
Gender : Male
What is this child's relationship to you? : Child
Parent One : Me
Parent Two : Unknown
Has this child been in your care since they were Yes
born? :

Page 4 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

Partner Situation
Do you have a partner? : No
What best describes your relationship status? : Single
Do you have children in your care? : Yes
Have you ever lived with a partner? : Yes
Are you applying for financial assistance because Yes
of a change in your relationship status? :
Is your partner in prison? : No
Years : 3
Months : 4
When did you separate from your partner? : January 13, 2023
Please describe, in your own words, the reason Toxic
or event in your relationship that resulted in you
separating from your partner :
What do you consider to be the future of your Over
relationship? :
Do you have a shared care arrangement for any of No
the children in your care? :
Do any of your children usually live away from No
home (other than a shared care arrangement)? :
Are you and the partner you separated from still No
living in the same house? :
Do you have any other children who are Yes
dependent on you? :

Residency Details
Residency Status : NZ Citizen (by birth)
Do you usually live in New Zealand and intend to Yes
stay here? :
Have you lived in New Zealand continuously Yes
for at least two years since you became a New
Zealand citizen or permanent resident? :
Other than New Zealand and the country you No
were born in (if not NZ), are there any additional
countries you have lived in? :
Do you receive or qualify for a social security No
benefit, pension or allowance from overseas? :
Which ethnic group do you identify with? : New Zealand European

Page 5 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

Work information Details

Have you worked in the last 52 weeks? : Yes
Are you currently working? : Yes
Do you have work that is finishing? : No
Have you had any other work in the last 52 No
weeks? :

Work Details
Is this your current work? : Yes
Employer Name : ACC

Current Work Details

What is your weekly wage before tax (gross 678.40
weekly wage)? :
What type of work do you do? : Part time
How many hours per week do you work? : 25
Does the number of hours you work regularly No
change? :

Other Income Details

In the last 52 weeks did you get any other income Yes
or payments? :
Do you expect to get other income in the next 52 No
weeks? :

Received Other Income Details

What was the source of this income? : Other income
Please provide details of this income : Family tax credits
Who were the payments made to? : You
How much was the total amount of this income 368.00
before tax? :

Training Or Study Details

Are you studying at a school or any other No
educational institute? :
Have you finished full-time study or training in No
the last 28 days? :
Have you enrolled to study full-time at a school or No
any other educational institute? :

Page 6 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

Health Details
Are you pregnant? : No
Do you have a health condition, injury or Yes
disability? :
Health Condition : Yes
Disability : No
Injury : Yes
Totally blind : No
Life expectancy less than two years : No
Does this health condition, injury or disability Yes
affect your ability to work? :
Can you work part time? : No
Will your health condition, injury or disability Yes
stop you working part time for the next two years
or more? :
Is your health condition, injury, or disability a Yes
result of an accident? :
Have you applied, or will you apply, for earnings- Yes
related accident compensation payments? :
Who will make these payments? : ACC
When did you apply (dd/mm/yyyy)? : June 1, 2020
What is your ACC reference number? : 10049979756

Caring For Others Details

Are you caring full time for someone with a No
health condition, injury or disability who would
otherwise be in a hospital, rest home or residential
care? :

IRD and/or Bank Account Details

Inland Revenue tax number : 67988965
The account is in the name of : Megan Sisley
Bank : 38
Branch Number : 9005
Account Number : 0064397
Suffix Number : 01

Medical Costs Details

Do you or any member of your family have No
ongoing costs because of a disability which is
likely to last at least six months? :

Page 7 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

Essential Living Costs Details

Are you struggling to meet your essential living Yes
costs from what income you earn or from other
sources? :
Do you and / or your partner receive any Yes
Working for Families Tax Credit payments from
Inland Revenue? :
Do you and / or your partner have essential costs No
that you have to pay to keep working? :
Do you and / or your partner have any regular No
essential costs? :
Do you and / or your partner need a telephone for No
safety or security reasons, or because of special
family circumstances? :
What steps have you and / or your partner I cant improve income two sources of income
taken to get other help, reduce costs, or increase (ACC,tax credits) is all i can get.
income? :

Cash & Non Cash Assets Details

Do you or your partner have any cash assets? : No
Do you or your partner have any non-cash Yes
assets? :

Non Asset Details

What type of asset is it? : Other non-cash assets
Other non-cash assets : Car
What is its total value? : 5,000.00
How much money do you still owe on it? : 0.00

Childcare Assistance Details

How many hours a week do you spend at that 0
activity? :
How many hours a week do you spend travelling 0
from the centre to your activity and returning? :
How many hours a week do you spend at your 0
course? :
How many hours a week do you spend on other 0
study? :
How many hours a week do you spend travelling 0
from the centre to your course and returning? :
Do you have childcare costs? : No

Page 8 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

Essential Living Working for Families Tax Credit Payment Details

Payment Type : Family tax credit
How often are your payments? : Weekly
How much is each payment? : 368.00
Who gets this payment? : Myself

Page 9 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

Client's Obligations
Please read this statement carefully.

I must tell Work and Income or my Contracted Service Provider (where I have one assigned to me) immediately
if I:
• have a change in work situation (such as starting part-time, casual or full-time work, whether paid or unpaid)
• become self-employed / start to run a business
• have changes to my income or financial circumstances
• intend to travel overseas
• start / finish part-time or full-time study
• have changes to personal details (such as name, address, contact details or bank account number)
• have changes to my living situation (such as marriage or separation, starting or ending a civil union, starting or
ending a de facto relationship, change in the number of children supported, change in accommodation costs)
• are imprisoned / held in custody on remand
• are admitted to or discharged from hospital
• have been granted an overseas pension
• have any other change that may affect my benefit entitlement or rate.

Page 10 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

Client's Obligations
Please read this statement carefully, and sign.

I understand that while I get this benefit I'll have an obligation, when asked, to:
• attend and participate in interviews to determine if I have the capacity to have work preparation obligations
• attend and participate in work ability assessments.

I understand that if I'm assessed as having the capacity, I'll have the following work preparation obligations to:
• attend and take part in work preparation interviews, where Work and Income ask me to
• attend and take part in work related activities or programmes such as a work assessment, a programme or seminar to
increase particular skills or enhance motivation where Work and Income ask me to
• attend and take part in any other activity that Work and Income require me to (including rehabilitation but not
medical treatment, voluntary work or activity in the community).

Where I've been asked to, I'll have an obligation to attend and participate in a work ability assessment.

Where I've been asked to work with a Contracted Service Provider I'll have an obligation to co-operate with
them and to:
• attend and participate in any interview with them
• report to them on how I'm meeting the obligations above
• complete assessments with them.

I understand that while I'm getting this benefit I'll be expected to take reasonable steps to meet certain
obligations as a parent or a caregiver. These are to ensure my dependent child(ren) (including any child I get
Orphan's or Unsupported Child's Benefit for) are:
• enrolled with a primary health care service (eg medical centre)
• enrolled in and attending one of the following from the age of three until they start school:
– an approved early childhood education programme or
– Te Aho o Te Kura Pounamu - The Correspondence School or
– another approved parenting and early childhood home education programme
• up to date with core Well Child/Tamariki Ora checks
• enrolled in and attending school from the age of five or six (depending on when they start school).

I understand that I may be required to meet with Work and Income to discuss how I'm meeting my obligations as a
parent or a caregiver.

I understand that I must meet these obligations and that:

• the first and second time I don't meet my obligations, without a good and sufficient reason, my benefit will be
reduced by 50% or stopped. I understand that my benefit will increase or restart if I undertake the activity I failed to
do
• the third time I don't meet my obligations, without a good and sufficient reason, my benefit will be reduced by 50%
or stopped, for 13 weeks. If my benefit has been reduced or stopped, and I agree to take part in an approved activity
for at least six weeks and I'm still entitled to my benefit, it will be increased or restarted
• when my benefit is reduced or stopped this may affect my entitlement to any supplementary assistance I am
receiving.
• I have the right to review or dispute any decision to reduce or stop my benefit.

My obligations have been explained to me and I understand my responsibilities.

I understand that if I have made an application for Temporary Additional Support, I must take all necessary steps to get
other assistance towards costs and take reasonable steps to increase my income and reduce costs where possible.

Page 11 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

I agree that personal information relating to job search and training may be collected and given to prospective
employers, the Tertiary Education Commission, Workbridge, training providers, career services or other agencies
which have a formal agreement to provide services on behalf of Work and Income.

I understand that if I intend on travelling overseas and don't let Work and Income know before I leave New Zealand,
my benefit will be stopped.

I have completed all the questions or they have been completed for me in the following applications:

Supported Living Payment

Accommodation Supplement
Disability Allowance
Temporary Additional Support

The information I have given is true and complete. The conditions for receiving this assistance have been explained to
me and I understand these conditions.

I am also aware of and understand the Privacy Act statement.

Name (print) Client's signature

Day Month Year

Page 12 of 13
 Name: Megan Sisley
SWN: 394700005
Reference Number: 2978330
Submitted Date: 05/02/2023

Statement by Interviewing / Interpreting Officer

I have explained the conditions for receiving a benefit and explained what the client's obligations mean and the reason
for them. The client has indicated that he / she understands and accepts responsibility to provide true and complete
information and to advise immediately of any changes in circumstances. All questions have been completed.

If application made under grounds of hardship.

Asset details completed.

Name (print) Interviewer's signature

Day Month Year

Additional information:

Decision:

Processor's signature

Day Month Year

Authenticator's signature

Day Month Year

10% 100% Critical Checker's signature
Data
Day Month Year

Page 13 of 13