$5k to Work

incentive payment application

The $5k to Work incentive payment is to help you relocate to another area in
New Zealand to take up full-time work. This can include seasonal work if it’s for more
than 91 days.
To get this, you or your partner must qualify for a main benefit and there are also some
other conditions.

Write your client number here. It can be found on your Community Services Card.
Client number

Your details 1 What is your full name?

ATTACHMENT FOR Q1:

First and middle names Surname or family name
Please provide proof of your
identity when you apply. For
example your passport or
driver licence.
2 What date were you born?

Day Month Year

HOW TO ANSWER Q3: 3 Where do you live now?

If you live in a rural
Flat/House number Street name
area, flat/house number
could include your RAPID
number, fire number,
emergency services Suburb
number.

Town/City

HOW TO ANSWER Q4: 4 Is your mailing address different from where you live now?
Mailing address can
include a PO Box, rural No Yes Tell us your mailing address
delivery details, or C/O
address.

HOW TO ANSWER Q5: 5 How else can we contact you? Tick the best way for
Please only give us us to contact you
contact details you’d like Home phone (   )
us to use.
Mobile phone (   )
Other phone (   )
Email

LAB1020W – OCT 2020 Page 1

Your new job 6 What are the details of the business you’ll be working for?
Business name
ATTACHMENT FOR Q6:
You’ll need to provide
proof of your new job.
Business address
Examples of proof Street number Street name
include:
• signed employment
contract Suburb Town/City
• letter of offer from the
employer.
Employer’s name

Employer’s contact details

Phone (   )
Mobile phone (   )
Fax (   )
Email

INFORMATION FOR Q7: 7 What industry is the job in?

Examples of industries
include:
• construction
• hospitality
• horticulture, etc. 8 What date do you start?

Day Month Year

9 What is your before-tax pay rate?

$ Weekly Fortnightly Monthly

10 Is your employment for more than 30 hours a week?

No Yes

11 Is your employment expected to last for more than 91 days?

No Yes

HOW TO ANSWER Q12: 12 If you’re cancelling your benefit, do you want to apply for the three months
Choosing YES will Debt Recovery Suspension?
mean you won’t have
to make payments to
No Yes Not applicable
your benefit or Student
Allowance debt for three
months, when you start
full-time work.

Page 2 LAB1020W – OCT 2020

Your new 13 Where will you be living when you move to the new area?
accommodation Flat/House number Street name

Suburb

Town/City

HOW TO ANSWER Q14: 14 Will your mailing address be different from where you will live?
Mailing address can
include a PO Box, rural No Yes Tell us your mailing address
delivery details, or C/O
address.

HOW TO ANSWER Q15: 15 What will your contact details be when you are in the new area?
Please only give us Tick the best way for
contact details you’d like us to contact you
us to use.
Home phone (   )
Mobile phone (   )
Other phone (   )
Email

Declaration and signature

By signing this form I understand that:
• The Ministry of Social Development can recover the $5k to Work incentive payment if I leave my job without
a good and sufficient reason and return to benefit or study within 91 days of starting work, or don’t use the
payment for the purposes for which it was granted (for example, if I don’t relocate or start work).
• I can only receive one incentive payment to relocate in a 52 week period.
• The Ministry of Social Development may contact my employer for confirmation of my employment and/or to
confirm that I’m in employment for more than 91 days.
• The information I have given is true and complete.

Your name (print) Your signature Date

Day Month Year

LAB1020W – OCT 2020 Page 3