Disability Allowance Form - New Zealand

S03 – OCT 2011
3S03 – OCT 2011
Privacy Statement
The legislation administered by
the Ministry of Social Development
allows us to check the information
that you give us in this form.
This may happen when you apply
for a benet and at any time after
Work situation changes include starting
part-time, casual or full-time work,
whether paid or unpaid.
Changes in your living situation include:
marriage or separation
starting or ending a civil union
starting or ending a de facto
relationship with someone of the
same or opposite sex
change in the number of children
change in accommodation costs.
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 contained in this application form.
Client’s name (print) Client’s signature
Day Month Year
Partner’s name (print) Partners signature
Day Month Year
The Privacy Act 1993 requires us to tell you that:
The information you give us is collected under the authority of the legislation administered by the
Ministry of Social Development.
The information will be held by the Ministry of Social Development.
The information is collected for the purposes of the legislation administered by the Ministry of
Social Development (including Work and Income, Child, Youth and Family and other service lines
of the Ministry), and in particular for:
granting benets and other assistance under the Social Security Act 1964
providing employment related services
statistical and research purposes
providing advice to Government
care and protection needs of children
providing support and services for you and your family
providing education related services.
Work and Income may contact health providers to verify any health related information you give us.
Work and Income may give employers information about you to nd you employment. Where
Work and Income refer you to a job vacancy, we may also contact the employer to discuss the
result of any job interview that you attend.
Work and Income may share information you have given us with childcare centres to administer
your entitlement to childcare assistance.
Other information that you give us on your skills, aspirations, family circumstances etc, and that
is not required to assess your entitlement to a benet may be used to provide a better service to
you by the Ministry of Social Development.
The information you give us may be compared with information held by Inland Revenue, the
Ministry of Justice, the Department of Corrections, the New Zealand Customs Service, the
Department of Internal Affairs, the Accident Compensation Corporation, Housing New Zealand
Corporation, Ministry of Health and Immigration New Zealand. It may also be compared
with social security information (for example, pension or benet information) held by other
governments (including Australia and the Netherlands).
Under the Tax Administration Act 1994, if you have dependent children, the information you give
us may be shared with Inland Revenue for the purpose of administering Working for Families Tax
Credits. Inland Revenue may also:
use the information for the purposes of child support, student loans and taxation
disclose it to the Department of Labour, Statistics New Zealand, the Ministry of Justice, the
Accident Compensation Corporation, and the Ministry of Education
disclose your personal information to your partner.
Under the Privacy Act 1993 you have the right to ask to see all information we hold about you,
and to ask us to correct that information.
You are not required to give us information, but if you do not give us all the information we ask
for, your application for benets may be declined.
I must tell Work and Income immediately if either my partner or I:
have a change in work situation
become self employed / start to run a business
have changes to my / our income or nancial circumstances
intend to travel overseas
start / nish part-time or full-time study
have changes to personal details (such as name, address or bank account details)
have changes to my / our living situation
am imprisoned / held in custody on remand
am admitted to or discharged from hospital
have been granted an overseas pension
have any other changes that may affect my / our benet entitlement or rate.
I understand that:
if I have made a false statement or
if I have failed to answer all the questions in full or
if I do not tell Work and Income about changes in my life that might affect my entitlement or rate
my benet may be reviewed and cancelled and
I may have to pay back the total amount of any overpayment that I have received and
Work and Income may impose a penalty (up to three times the value of the overpayment) or
I may be prosecuted and ned or imprisoned.
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