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 benet and at any time after
that.
Important
Obligations
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 •
supported
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 benets 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 benet 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 benet 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 benets 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 benet 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•
then
my benet 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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