Disability Allowance Form - New Zealand
S03 – OCT 20116
OffICE USE ONLy
Statement by Interviewing / Interpreting Ofcer
I have explained the conditions for receiving a benet 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.
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 data Checker’s signature
Day Month Year
Bring up B f
Day Month Year
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Disability Allowance Form - New Zealand PDF
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