Disability Allowance Form - New Zealand
S03 – OCT 20112
S03 – OCT 2011
Expenses
Q17 note: You must provide invoices,
receipts, quotes or printouts for each
additional expense before they can be
considered as an ongoing cost for Disability
Allowance. These must be attached to this
form when you have completed it.
All of these expenses must be directly
related to the disability and veried
as necessary by a registered medical
practitioner.
Do not include costs that are covered by a
War Disablement Pension.
17. What additional expenses are paid for as a result of the disability?
How often Verication
List pharmaceuticals/items/services/treatments (eg daily, weekly, provided
(eg medical costs, gardening, transport, medical alarms) Cost? monthly)? (please tick 3)
$
$
$
$
$
Partner
Q9 note: A partner is your spouse
(husband or wife), your civil union
partner, or a person of the same or
opposite sex with whom you have a
de facto relationship.
9. Do you have a partner?
No
u
Are you: Single Living apart/ separated Divorced
Widowed Civil union dissolved
Yes
u
Are you: Married In a civil union In a relationship
10. What is your partner’s name?
11. What is your partner’s date of birth?
Day Month Year
Income
Q12 note: Examples of income from
other sources:
wages or salary •
accident compensation •
farm or business income (include •
drawings)
self employment •
interest from savings or investments •
dividends from shares •
income from rents •
redundancy or termination type •
payments
Child Support •
maintenance payments •
boarders •
Student Allowance, scholarship or •
Student Loan living cost payments
any other income, eg family trusts, •
overseas payments.
Give gross (before tax) amount.
12. Did you or your partner (if you have one) get income from any other source in the last 52
weeks?
No Yes
u
Please provide details below:
Source (eg bank account number) You Your partner Jointly
$ $ $
$ $ $
$ $ $
13.
Do you or your partner (if you have one) expect to get other income in the next 52 weeks?
No Yes
u
Please provide details below:
Source (eg bank account number) You Your partner Jointly
$ $ $
$ $ $
$ $ $
Disability Allowance
Q14 note: Please tick one box only.
You may be able to get Child
Disability Allowance for the same
dependent child. Please talk to us
about this.
Entitlements
14. Who are you applying for?
Yourself
u
Go to Question 15 Your partner
u
Please provide their full name below:
Your dependent child
u
Please provide their full name below:
First name(s) Surname Relationship to you
15. Is this disability covered by private medical insurance?
No Yes
u
Please provide details below:
16. Is this disability covered by ACC or War Disablement Pension?
No Yes
u
If ‘Yes’, you may not be entitled to a Disability Allowance
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