New Zealand

Superannuation
application
Why not fill in your application online? You’ll only be asked questions that are relevant to you. In most cases,
if you apply online, you can post the signed summary to us and won’t need an interview.
To apply online or for more information go to workandincome.govt.nz or call us on 0800 552 002.
If you’re completing this form, we suggest you read the instructions on pages 1 to 4 before you fill it in, so you
get a feel for what’s needed.
A SuperGold Card is a free discounts and concessions card. We’ll automatically send you a card soon after
your NZ Super is granted.

You may be able to get NZ Super if:

Who can get • you’re aged 65 years or over, and

NZ Super? • you’re a New Zealand citizen or permanent resident
• live in New Zealand at the time you apply
• you’ve lived in New Zealand for at least 10 years since you turned 20, and
• you’ve lived in New Zealand, the Cook Islands, Niue and/or Tokelau for at least five
years since you turned 50.
There are exceptions to some of these residency requirements.
If you’re not sure if you meet these criteria, please contact us.

When you can apply

You can apply for NZ Super from 12 weeks before you turn 65 to avoid missing out on
How to apply payments. If you apply after you turn 65 your payments may only start from the date
you apply.
What you need to do
You and your partner (if you have one) need to:
1. Fill out this application form.
2. Collect all the documents you need to show us. We tell you about these in the
application form (look for the ), and we also have a list on page 3.
3. Bring this application form and your documents to a meeting. We’ll make sure we
have all the information we need and can answer any questions you might have.
If you don’t already have a meeting arranged, contact us on 0800 552 002 so we
can set one up for you.

You must give us all the information we need.

If you don’t have all the information we need, talk with us and we may be able to help.
If we find out later that any information you give us is not true, or that you knew information you
should have told us and did not tell us, we may stop paying your benefit. You might need to pay
money back. In some cases you could even be prosecuted.

M12 – Nov 2020 Page 1

 Our
commitment
to YOU
We will get to know you,
your situation and Ka mohio We will make sure you
understand everything
your needs ki a koe you need to know

know
you
We will use your We will respect your
feedback to improve privacy and be clear
our service­ about how we use
your information and
who we share it with

We will let you know

everything you may Ka tautoko We will help you
 owever we can,
h
be eligible for­ i a koe as soon as we can

support
you
The information We will be honest
we give you will a bout our mistakes
be accessible and and put them right
consistent no matter
how you contact us­

We will respect you

and what is important Ka mahi We will work
together to achieve
to you tahi ki a koe shared goals

with
you
We will let you know Our actions will
your options, rights follow our words
and obligations

How did
wedo? Let us know by visiting msd.govt.nz/feedback
or call us on 0800 552 002

Page 2 M12 – Nov 2020

New Zealand
Superannuation
checklist
Once you’ve filled out the application form, use this checklist to tick off all the documents you need
for your meeting with us.
Talk to us if you don’t have any of the documents, have given them to us recently or if there might be a
delay in getting them.
If you have a partner, there may be documents they need to provide, for example if you apply for Extra
Help. There’s also more information about partners on the next page.

What you Proof of who you are:

need to
provide If you were born in New Zealand, bring one type of official identification
that has your full legal name and your date of birth (for example, your birth
certificate, passport, driver licence, firearms licence, deed poll).
INFORMATION NOTE:
If you were born overseas, bring proof that you have a right to live
Documents need to be
originals, or copies of
in New Zealand (for example, a citizenship certificate, a New Zealand
documents that have passport, a passport from another country with residence class visa or
been certified as a true proof of permanent residence).
copy by a Solicitor/Lawyer,
Notary Public, Registrar Your partner may also need to provide this.
of the Court or Justice of
the Peace.
If your name has changed, bring your marriage certificate, deed poll, or
other proof of the name change.

You need to bring two more documents that help to prove who you are
(for example, a marriage certificate, bank statement, phone or power
account, driver licence).

If you’re using your residence in the Cook Islands, Niue and/or Tokelau to
qualify for NZ Super you need to provide proof of the time you lived in those
countries.

Proof of your bank account, such as a bank statement or deposit slip

showing the account name, account number and bank logo. If you have to
write any of these details yourself, you need to get the bank to stamp and
sign the statement or slip.

One of the documents above must be at least two years old.

M12 – Nov 2020 Page 3

 If you have a partner, we need to know some details about them. It’s important we
have this information because it can affect the amount we can pay.
If you have a
We also need to know about whether your partner has or is likely to have any
partner
entitlement to an overseas pension. Their overseas pension may affect any Extra
Help you get. There’s more information about overseas pensions on our website.

If you’re going overseas you may still be able to get all or some of your NZ Super.

Going We can give you advice about:

overseas • any effect your trip may have on your payments
• avoiding an unexpected debt
• being left stranded overseas without any money if things happen that delay your
return to New Zealand.

For more information about going overseas:

• visit workandincome.govt.nz and search on NZ Super going overseas
• call us on 0800 552 002.

Page 4 M12 – Nov 2020

New Zealand
Superannuation
applicant form
In the applicant form, ‘you’, ‘your’, and ‘yourself’ means the person
applying for NZ Super.
If we say ‘your partner’ this only applies if you have one.

Tell us about yourself

If you’ve received a benefit or extra financial help from us before, write your client number here if you know it.
This number can be found on your Community Services Card if you have one.
Client number

Tell us the 1 What is your full name?

names you’ve Mr Mrs Ms Miss Other
been known by First and middle names
ATTACHMENT FOR Q1:
Bring proof of who you Surname or family name
are. What you need to
bring is explained on
page 3.

2 Is the name on your birth certificate the same as above?

No Tell us the name that is on your birth certificate Yes
First and middle names

Surname or family name

HOW TO ANSWER Q3: 3 Have you ever been known by any other name?
For example, have you
had married names, No Yes Write them all out below
English names, changes
by deed poll, or aliases? 1.
ATTACHMENT FOR Q3: 2.
Bring your marriage
certificate, deed poll,
or other proof of any 4 What name would you like us to call you?
name change.
The name I wrote in Question 1 The name I wrote in Question 2

Other Write the full name

M12 – Nov 2020 Page 5

Tell us more 5 What date were you born?
about you
Day Month Year

6 Are you:
Male Female Gender diverse

7 Are you currently receiving weekly compensation payments from ACC?

No Yes

If you get weekly compensation payments through ACC, in most cases you can’t get NZ Super for
the same period. You may be able to get NZ Super if ACC have confirmed:
• you can get both payments for a period of time, or
• the date your ACC payment stopped.
If you need help call ACC on 0800 101 996.

8 What is your Inland Revenue tax number?

INFORMATION FOR Q9:

9 What tax code do you want to use for your NZ Super payments?
If you don’t give us a tax
code, your payment will
be taxed at the higher
‘no-notification rate’
of 45% You can work out your tax code using the online calculator at ird.govt.nz or phone
Inland Revenue on 0800 227 774.
ATTACHMENT FOR Q9:
If you use tax code ‘STC’
please provide proof from
Inland Revenue.

Tell us how 10 Where do you live?

we can Flat/House number Street name
contact you
Suburb
HOW TO ANSWER Q10:
If you live in a rural
area, flat/house number
could include your RAPID Town/City
number, fire number,
emergency services
number.
11 Is your mailing address different from where you live?
HOW TO ANSWER Q11:
Mailing address can No Yes Tell us your mailing address
include a PO Box, rural
delivery details, or C/O
address.

Page 6 M12 – Nov 2020

HOW TO ANSWER Q12:
12 How else can we contact you? Tick the best way for
Please only give us us to first contact you
contact details you’d like Home phone (   )
us to use.
Mobile phone (   )
Other phone (   )

13 Do you agree to get emails from us, including information about discounts
and concessions for SuperGold Card holders?
No Yes Tell us your email address I don’t have an email address

A SuperGold Card will be sent to you automatically, once your NZ Super is granted. It gives you
access to thousands of discounts and concessions from businesses around New Zealand and
Australia, and to New Zealand government and/or local council services.

Tell us your 14 Tick the group(s) you most identify with.

ethnicity Māori Which tribe(s) or iwi?

INFORMATION FOR Q14: New Zealand

Niuean Samoan Indian
We collect this European
information for statistics Other European Tokelauan Tongan Chinese
we use in research and
future development work.
Cook Island Māori Other Please write below Don’t want to answer

Tell us 15 Do you usually live in New Zealand?

about your No Yes
residence
status
16 Do you regularly visit any countries outside New Zealand?
HOW TO ANSWER Q15:
This means you consider
New Zealand your home, Name of country you Reason for visiting (for example,
you’re a legal resident, visit or will visit How often? How long? holiday, working, living)
you currently live here on
a day-to-day basis and
you intend to stay.
In deciding if someone
is ordinarily resident we
look at:
• time spent in New
Zealand and your
intentions for the future
• property and assets
you own here
• which country your bank
accounts, cash assets
and investments are in
• whether your income is
earned here or overseas
• whether you pay tax here
• whether you’re eligible
to vote here
• your involvement in the
community, clubs and
other groups.

M12 – Nov 2020 Page 7

 17 What best describes your residence status in New Zealand? Tick only one box.
New Zealand citizen Go to question 20
by birth

Granted New Zealand

Date citizenship granted
citizenship
Day Month Year
Go to question 18
HOW TO ANSWER Q18:
If you were under 20 Granted permanent Date permanent
years old when you first residency residence granted
Day Month Year
arrived in New Zealand,
we can accept an Go to question 18
approximate date
of arrival. If you were
over 20 and aren’t sure of Other What is your residence status?
the actual date, talk to
us and we can decide
whether the date
needs to be confirmed.
18 When did you arrive in New Zealand?
HOW TO ANSWER Q20:
Please answer this
question even if you Day Month Year
were born in
New Zealand. 19 What country were you born in?
Your answers to
questions 20 and 21
tell us if you meet the
residence criteria.
20 How many years, from the age of 50, have you lived in any of the following
ATTACHMENT FOR Q20: countries?
If you’re using your
New Zealand Cook Islands Niue Tokelau
residence since turning
50 in the Cook Islands,
Niue and/or Tokelau to None If your answers in these boxes add up to 10 years or more go to question 22
qualify for NZ Super,
you need to provide
proof of the time 21 How many years have you lived in New Zealand between the ages of 20 and
you’ve lived in those 50 years old?
countries. Ask us if you
need help with this.

Tell us if 22 Have you ever lived or worked in any countries outside of New Zealand?
you’ve lived Do not include holidays of four weeks or less.
or worked No Go to question 25 Yes Please list details below
overseas
Humanitarian work

INFORMATION FOR Q22:

Missionary work
Visiting family

Periods of overseas
residence may:
Holiday

• affect entitlement to
Other
Study

Date you entered Date you left

Work

some benefits
Name of country this country this country
• mean you’re eligible for
an overseas benefit or /  / /  /
pension.
/  / /  /
For more information,
phone 0800 777 227. /  / /  /
HOW TO ANSWER Q22: /  / /  /
Your reason for being in
a country may be that /  / /  /
you were there for a /  / /  /
working holiday, you were
living there, you were /  / /  /
born there. If you don’t
/  / /  /
know the exact date we’ll
accept a month and year.

Page 8 M12 – Nov 2020

 23 Do you get or qualify for a social security benefit, pension or allowance
from overseas?

You need to tell us this because your payments may be affected if you get or are eligible for an
overseas pension or benefit.

No Go to question 25 Don’t know Go to question 25

Yes Tick the box that best describes your benefit, pension or allowance

Retirement or old age Superannuation Disability or health

condition
Widow or survivor Child or dependent War related

Other

ATTACHMENT FOR Q24: 24 If you ticked ‘Yes’ for question 23, please give details of the payments
You’ll need to show you get.
us proof of these
payments, such as a Payment 1 Payment 2
pension certificate. What country does the payment come from?
How much do you get each time the payment
is made (in overseas currency)?
Is this amount before or after tax?
How often do you get the payment
(for example, weekly, fortnightly, monthly)?
What is the name of your pension, allowance
or benefit?
What is the payment reference number?

Tell us your 25 What bank account would you want your payments to be paid into?
bank details The account is in the name of:

ATTACHMENT FOR Q25:

You need to provide The account number is:
proof of your bank Bank Branch Account number Suffix
account details, such
as a bank statement or
deposit slip.

Tell us 26 Have you served with the New Zealand Armed Forces?
whether you’re No Yes If you’ve ticked ‘Yes’, you may be entitled to a:
a veteran • Veteran’s Pension (for more information call 0800 650 656), and/or a
• War Disablement Pension or associated payments
(for more information call Veterans’ Affairs New Zealand on
0800 4 VETERAN (0800 483 8372)).

M12 – Nov 2020 Page 9

Tell us about your household
If you meet our definition of living alone, we may be able to pay you a higher rate of NZ Super to recognise the cost of maintaining
your home on your own.
You may also get this if you have a partner who’s in residential care, hospital or prison, or in other situations when you’re not living
on your own. You can have visitors stay with you for up to 13 weeks and still get the living alone rate.

Tell us about 27 Do you live alone?

your living I live with my partner Go to question 31
situation
I live with other people Go to question 28

Yes Go to question 29

INFORMATION FOR Q28: 28 Please provide details for anyone you live with:
We don’t need to know
the name of each person. Person 1
Relationship to you
ATTACHMENT FOR Q28:
If you need to include Is this person 18 years or younger?
more than three people in
your application, please No Go to the next person or question 31
write these details about
each one on a separate Yes Answer the following
sheet of paper, and bring
them with this application
What is their date of birth?
form.
Day Month Year
Does this person attend school or a tertiary institution?
No Yes

Person 2
Relationship to you

Is this person 18 years or younger?

No Go to the next person or question 31

Yes Answer the following

What is their date of birth?

Day Month Year
Does this person attend school or a tertiary institution?
No Yes

Person 3
Relationship to you

Is this person 18 years or younger?

No Go to the next person or question 31

Yes Answer the following

What is their date of birth?

Day Month Year
Does this person attend school or a tertiary institution?
No Yes

Page 10 M12 – Nov 2020

 29 Do you have any visitors aged 18 years or older who’ll be staying with you for
13 weeks or longer?
No Yes

INFORMATION FOR Q30: 30 What is your accommodation?

‘Self-contained’ for
a granny flat or unit House or flat A room in a boarding house
means there is a kitchen
or a kitchenette and a Self-contained ‘granny’ flat Hotel or motel
bathroom.
‘Self-contained’ for a Self-contained unit in a retirement village or rest home
mobile home means it
needs to have facilities for: Mobile home – self-contained
• day-to-day living
• sleeping A boat moored within New Zealand territorial waters
• preparing and cooking
Accommodation in a caravan park
food
It must also have a: Other Please provide details below
• sink
• toilet
• fresh water tank
• waste water tank

Tell us if you We need to know if you have a partner or husband or wife and some information about them.
have a partner This is so we can pay you the right rate.
By ‘partner’ we mean someone you’re in a relationship with. If you’re not sure, you can leave this
section blank until you talk to us. In the meantime, go to question 40.

31 Do you have a partner?

No Go to question 40 Yes

32 What is your partner’s full name?

33 What is your partner’s date of birth?

Day Month Year

34 Is your partner:
Male Female Gender diverse

35 What is your relationship status with your partner?

Tick one of the following boxes

Married In a civil union In a relationship

M12 – Nov 2020 Page 11

INFORMATION FOR Q36:
36 Are you living at the same address as your partner?
If your partner is living
at a different address, for No Yes Go to question 38
example a rest home, you
may qualify for a living
alone rate. 37 Where does your partner live?
Rest home Public hospital Private hospital Prison

Other Please tell us where they live

If your partner doesn’t qualify for their own NZ Super and they still need financial help, they’ll
need to apply for another benefit of their own.
If they’re not sure what the best option is, please talk with us.

38 Does your partner need any financial help from us?

No Your partner needs to complete the partner’s residence form on page 14

Your partner will need to apply for their own benefit. Talk to us about
Yes
the best option.

39 Is your partner getting a benefit, Student Allowance or Loan or NZ Super?

No Your partner needs to complete the partner’s residence form on page 14

Yes What is their client number?

Extra Help information

You may be able to get extra financial or other help. Most extra help we pay depends on your personal situation
and what income or assets you have. You can apply for extra help at any time.
For more information about extra help and application forms go to workandincome.govt.nz or you can phone
us on 0800 552 002.

Disability If you, or a family member, have a disability or medical condition likely to continue for at least six
Allowance months, you may be able to get help with costs such as ongoing visits to the doctor, medicines,
medical alarms, travel, and some other costs.
Disability Allowance is income tested.

40 Do you want to apply for a Disability Allowance?

No Yes Please complete a Disability Allowance application

Page 12 M12 – Nov 2020

Accommo- If you have costs from owning your own home, renting, or boarding, you may be able to get
dation an Accommodation Supplement. How much you get will depend on your income, assets,
Supplement accommodation costs, family circumstances and where you live.
Accommodation Supplement is income and asset tested.
If you and/or your partner are tenants living in a public housing property, you won’t be able to get
Accommodation Supplement. (Public housing properties are provided by Housing New Zealand
and approved community housing providers.)

41 Do you want to apply for an Accommodation Supplement?

No Yes Please complete an Accommodation Supplement application

Temporary Temporary Additional Support helps with essential costs for a short time when you’ve tried
Additional everything you can think of, and still can’t pay for them.
Support To get Temporary Additional Support, your assets will need to be below a certain level.

42 Do you want to apply for Temporary Additional Support?

No Yes Please complete a Temporary Additional Support application

Community The Community Services Card can help you with the costs of health care. You’ll pay less for some
Services Card health services and prescriptions.
To be eligible for the Community Services Card, your income must be below a certain level.

43 Do you want to apply for a Community Services Card?

No Yes Please complete a Community Services Card application

Dependent A dependent child is a child who is financially supported by you and is living with you as a member
children in of your family.
your care
44 Do you have dependent children in your care?
No Yes You may be able to get other forms of financial assistance. Please
ask us about this.

If you don’t have a partner, please go to page 17

M12 – Nov 2020 Page 13

New Zealand
Superannuation
partner’s residence form
This partner’s residence form should be completed and signed by the partner of the person applying
for NZ Super if they’re:
• not already getting NZ Super
• not already getting a benefit.
We need this information so we can pay you the right rate. For more information about why your partner needs
to complete this form, please read the ‘If you have a partner’ section on page 4.
In this form, ‘you’, ‘your’, and ‘yourself’ means the partner of the person applying for NZ Super. By partner, we
also mean husband or wife.

Tell us about yourself

If you’ve received a benefit or extra financial help from us before, write your client number here if you know it.
This number can be found on your Community Services Card if you have one.
Client number

Tell us the 1 What is your full name?

names you’ve Mr Mrs Ms Miss Other
been known by First and middle names

Surname or family name

2 Is the name on your birth certificate the same as above?

No Tell us the name that is on your birth certificate Yes
First and middle names

Surname or family name

HOW TO ANSWER Q3: 3 Have you ever been known by any other name?
For example, have you
had married names, No Yes Write them all out below
English names, changes
by deed poll, or aliases? 1.
2.

Page 14 M12 – Nov 2020

 4 What name would you like us to call you?
The name I wrote in Question 1 The name I wrote in Question 2

Write the full name

5 What date were you born?

Day Month Year

6 Are you:
Male Female Gender diverse

Tell us 7 Do you usually live in New Zealand?

about your No Yes
residence
status
8 What best describes your residence status in New Zealand? Tick only one box.
HOW TO ANSWER Q7: New Zealand citizen Go to question 11
By answering yes, this by birth
means you consider
New Zealand your home, Granted New Zealand
Date citizenship granted
you’re a legal resident, citizenship
Day Month Year
you usually live here and Go to question 9
you intend to stay.
Granted permanent Date permanent
residency residence granted
Day Month Year
Go to question 9

Other What is your residence status?

HOW TO ANSWER Q9: 9 When did you arrive in New Zealand?

If you were under 20
years old when you
first arrived in New
Day Month Year
Zealand, we can accept
an approximate date of
arrival. If you were over 20
and aren’t sure of
the actual date, talk to 10 What country were you born in?
us and we can decide
whether the date needs
to be confirmed.

M12 – Nov 2020 Page 15

Tell us if 11 Have you ever lived or worked in any countries outside of New Zealand?
you’ve lived No Go to page 17 Yes Please list the details below
or worked

Humanitarian work
overseas

Missionary work
Visiting family
INFORMATION FOR Q11:
Periods of overseas

Holiday

Other
Study
Date you entered Date you left

Work
residence may:
• affect entitlement Name of country this country this country
to some benefits /  / /  /
• mean you’re eligible for /  / /  /
an overseas
benefit or pension. /  / /  /
For more information, /  / /  /
phone 0800 777 227.
/  / /  /
HOW TO ANSWER Q11:
/  / /  /
Your reason for being
in a country may be /  / /  /
that you were there for
/  / /  /
a working holiday, you
were living there, you were
born there. If you don’t
know the exact date 12 Do you get or qualify for a social security benefit, pension or allowance
we’ll accept a month from overseas?
and year.
No Don’t know

Yes Tick the box that best describes your benefit, pension or allowance

Retirement or old age Superannuation Disability or health

condition
Child or
Widow or survivor War related
dependent
Other

13 If you ticked ‘Yes’ for question 12, please give details of the payments
you get.
Payment 1 Payment 2
What country does the payment come from?
How much do you get each time the payment
is made (in overseas currency)?
Is this amount before or after tax?
How often do you get the payment
(for example, weekly, fortnightly, monthly)?
What is the name of your pension, allowance
or benefit?
What is the payment reference number?

Please go to the privacy information on page 19.

Page 16 M12 – Nov 2020

 What you need to do
(your obligations)

When you’re getting payments from us, there are some things you need to do to make sure you’re
getting paid the right amount.
If you don’t do these things, we could pay you the wrong amount. It could also mean we have to reduce or
stop your payments. We don’t want you to miss out on money you need so please read these carefully.

Let us know when things change

You need to let us know about changes that might affect the amount
you’re paid.
Changes to information about you or your family, like:
• name, address, contact details or bank account number
• starting or stopping living alone
• starting or ending a relationship, marriage, or civil union
• your partner passes away
• the number of dependent children you support.
We also need to know if you:
• go into or come out of hospital
• are being held in custody or on remand.
If we have the wrong information we could pay you the wrong amount. If we pay
you too much you might have to pay us back.

Tell us if you’re going overseas

If you’re travelling or moving overseas you may need to let us know because
we may have to change or stop your payments. Whether you need to let us
We can’t pay you while you’re know will depend on your travel plans. There are some examples below.
out of New Zealand unless
we’ve agreed to it. If there’s a good reason you can’t tell us before you go, then you need to let us
know as soon as you can.
To let us know your travel plans, you can complete a form on our website.
Go to workandincome.govt.nz and search on Overseas travel dates.
When you get other payments from us
If you get other payments from us like Winter Energy Payment, Disability
Allowance, Accommodation Supplement or Temporary Additional Support,
you can keep getting them only for the first 28 days you’re away. You need to let
us know about your travel plans before you go.
Travelling for short trips of 28 days (four weeks) or more
You need to let us know if:
• you’re going to be away more than 28 days, or
• you don’t know how long you’ll be away for, or
• you intend to have more than one overseas trip in the next 12 months.

M12 – Nov 2020 Page 17

 Travelling for 26 weeks or less
You can travel to any country for 26 weeks or less and keep getting your
payments as usual.
If you’re still overseas after 26 weeks your payment may stop. If you’re still over
there after 30 weeks you may have to repay all your payments since you left.
If you get held up because of circumstances beyond your control that you
couldn’t have known about before you left, you may be able to keep payments
made in the first 26 weeks.
Travelling for more than 26 weeks
If you have no intention of living in the countries you’re planning to visit, you may
be able to get all or some of your NZ Super while you’re away. At least six weeks
before you go, you need to contact us to apply to get your payments overseas.
What you’ll get depends on where you go and how long you’ve lived in New
Zealand.
Going overseas to live
You can live almost anywhere in the world and still get all or some of your
NZ Super. What you’ll get depends on where you go and how long you’ve lived in
New Zealand. Generally you must apply for payment overseas about 4-6 weeks
before you leave New Zealand. To arrange a meeting, call our International
Services team on 0800 777 227.

What can happen if you don’t meet your obligations

Your payments can stop if you don’t tell us something we need to know.

You need to do the things listed above to keep getting

payments from us.
If you don’t tell us something we need to know, your payments can stop. In some
You can find full details about cases you could even be prosecuted.
what can happen if you don’t
meet your obligations at
msd.govt.nz/not-meeting-
your-obligations

Your rights
You have the right to ask us to review any decision we make about your payments.

If you don’t think we have things right or there’s something

you don’t understand:
• call us – we can usually fix it over the phone
• you have the right to ask us to review the decision. Find out how at
msd.govt.nz/reviews

Page 18 M12 – Nov 2020

 How we protect your
privacy

Collecting your information

We collect your personal information, so we can provide income support, NZ Super or Veteran’s Pension, Student
Allowance, or Loans and connect you with employment, education and housing services. We do this under various
Acts, which are all listed on our website at workandincome.govt.nz/privacy
• To help us do this, we collect information about your identity, your relevant history, and your eligibility for our services.
• We get this information directly from you, and we sometimes collect information about you from others, including other
government agencies.
• You can choose not to give us your personal information, but we might not be able to help you if you don’t.

Using your information

We use the information you give us to make decisions about the best way to help you.
• These decisions may be about:
– whether you’re eligible for our services
– running our operations and ensuring our services are effective
– the services we’ll provide in the future.

Sharing your information

Sometimes, we need to share your information outside our Ministry to reach our goal of helping New Zealanders
to be safe, strong, and independent.
• To do this, we may share your information with:
– prospective employers to help you find work
– contracted service providers that help us to help you
– health providers if we need your medical information to assess your eligibility
– other government agencies when we have an agreement with them
– some other governments if you may be eligible to get or are getting an overseas pension.
• We also share personal information when the law says we have to.

Respecting you and your information

We make sure we follow the Privacy Act to do what’s right when we use your information.
• We treat you and your information with respect, by acting responsibly and being ethical.
• We make sure any technology we use meets strict security standards so it keeps your information safe.

Get in touch if you have a question

You have a right to ask to see your personal information, and to ask for it to be corrected if it’s wrong.
• If you have a question or a complaint, please get in touch.
• You can find full details about what we do with personal information in our privacy notice at:
workandincome.govt.nz/privacy

M12 – Nov 2020 Page 19

Signature page
Office copy

Applicant
I have answered all the questions that apply to me and my situation.
The information I have given you is true and complete.
I understand the things I need to do while I’m getting payments.
I will do what I need to do to meet my obligations.
I understand what you do with my personal information and how you protect my privacy.
Applicant’s name (print) Applicant’s signature Date

Day Month Year

Applicant’s partner
I have answered all the questions that apply to me and my situation.
The information I have given you is true and complete.
I understand what you do with my personal information and how you protect my privacy.
Applicant’s partner’s name (print) Applicant’s partner’s signature Date

Day Month Year

Helper’s statement
Complete this if you’ve helped the applicant or their partner to complete this application form.
Your first and middle names Your surname or family name

Your address

Your phone number

Tick the box for the statement that applies

I completed this application form at the request of the person applying. They told me they understood
what they were signing. The statements and answers I have completed are true and complete as given to
me by the person applying.
I completed this application form at the request of the partner of the person applying. They told me
they understood what they were signing. The statements and answers I have completed are true and
complete as given to me by the partner of the person applying.

Helper’s signature Date

Day Month Year

Page 20 M12 – Nov 2020

 What you need to do
(your obligations)

When you’re getting payments from us, there are some things you need to do to make sure you’re
getting paid the right amount.
If you don’t do these things, we could pay you the wrong amount. It could also mean we have to reduce or
stop your payments. We don’t want you to miss out on money you need so please read these carefully.

Let us know when things change

You need to let us know about changes that might affect the amount
you’re paid.
Changes to information about you or your family, like:
• name, address, contact details or bank account number
• starting or stopping living alone
• starting or ending a relationship, marriage, or civil union
• your partner passes away
• the number of dependent children you support.
We also need to know if you:
• go into or come out of hospital
• are being held in custody or on remand.
If we have the wrong information we could pay you the wrong amount. If we pay
you too much you might have to pay us back.

Tell us if you’re going overseas

If you’re travelling or moving overseas you may need to let us know because
we may have to change or stop your payments. Whether you need to let us
We can’t pay you while you’re know will depend on your travel plans. There are some examples below.
out of New Zealand unless
we’ve agreed to it. If there’s a good reason you can’t tell us before you go, then you need to let us
know as soon as you can.
To let us know your travel plans, you can complete a form on our website.
Go to workandincome.govt.nz and search on Overseas travel dates.
When you get other payments from us
If you get other payments from us like Winter Energy Payment, Disability
Allowance, Accommodation Supplement or Temporary Additional Support,
you can keep getting them only for the first 28 days you’re away. You need to let
us know about your travel plans before you go.
Travelling for short trips of 28 days (four weeks) or more
You need to let us know if:
• you’re going to be away more than 28 days, or
• you don’t know how long you’ll be away for, or
• you intend to have more than one overseas trip in the next 12 months.

M12 – Nov 2020 Page 21

 Travelling for 26 weeks or less
You can travel to any country for 26 weeks or less and keep getting your
payments as usual.
If you’re still overseas after 26 weeks your payment may stop. If you’re still over
there after 30 weeks you may have to repay all your payments since you left.
If you get held up because of circumstances beyond your control that you
couldn’t have known about before you left, you may be able to keep payments
made in the first 26 weeks.
Travelling for more than 26 weeks
If you have no intention of living in the countries you’re planning to visit, you may
be able to get all or some of your NZ Super while you’re away. At least six weeks
before you go, you need to contact us to apply to get your payments overseas.
What you’ll get depends on where you go and how long you’ve lived in New
Zealand.
Going overseas to live
You can live almost anywhere in the world and still get all or some of your
NZ Super. What you’ll get depends on where you go and how long you’ve lived in
New Zealand. Generally you must apply for payment overseas about 4-6 weeks
before you leave New Zealand. To arrange a meeting, call our International
Services team on 0800 777 227.

What can happen if you don’t meet your obligations

Your payments can stop if you don’t tell us something we need to know.

You need to do the things listed above to keep getting

payments from us. So does your partner, if you have one.
If you don’t tell us something we need to know, your payments can stop. In some
You can find full details about cases you could even be prosecuted.
what can happen if you don’t
meet your obligations at
msd.govt.nz/not-meeting-
your-obligations

Your rights
You have the right to ask us to review any decision we make about your payments.

If you don’t think we have things right or there’s something

you don’t understand:
• call us – we can usually fix it over the phone
• you have the right to ask us to review the decision. Find out how at
msd.govt.nz/reviews

Page 22 M12 – Nov 2020

 How we protect your
privacy

Collecting your information

We collect your personal information, so we can provide income support, NZ Super or Veteran’s Pension, Student
Allowance, or Loans and connect you with employment, education and housing services. We do this under various
Acts, which are all listed on our website at workandincome.govt.nz/privacy
• To help us do this, we collect information about your identity, your relevant history, and your eligibility for our services.
• We get this information directly from you, and we sometimes collect information about you from others, including other
government agencies.
• You can choose not to give us your personal information, but we might not be able to help you if you don’t.

Using your information

We use the information you give us to make decisions about the best way to help you.
• These decisions may be about:
– whether you’re eligible for our services
– running our operations and ensuring our services are effective
– the services we’ll provide in the future.

Sharing your information

Sometimes, we need to share your information outside our Ministry to reach our goal of helping New Zealanders
to be safe, strong, and independent.
• To do this, we may share your information with:
– prospective employers to help you find work
– contracted service providers that help us to help you
– health providers if we need your medical information to assess your eligibility
– other government agencies when we have an agreement with them
– some other governments if you may be eligible to get or are getting an overseas pension.
• We also share personal information when the law says we have to.

Respecting you and your information

We make sure we follow the Privacy Act to do what’s right when we use your information.
• We treat you and your information with respect, by acting responsibly and being ethical.
• We make sure any technology we use meets strict security standards so it keeps your information safe.

Get in touch if you have a question

You have a right to ask to see your personal information, and to ask for it to be corrected if it’s wrong.
• If you have a question or a complaint, please get in touch.
• You can find full details about what we do with personal information in our privacy notice at:
workandincome.govt.nz/privacy

M12 – Nov 2020 Page 23

Signature page
Applicant’s copy

Applicant
I have answered all the questions that apply to me and my situation.
The information I have given you is true and complete.
I understand the things I need to do while I’m getting payments.
I will do what I need to do to meet my obligations.
I understand what you do with my personal information and how you protect my privacy.
Applicant’s name (print) Applicant’s signature Date

Day Month Year

Please use the document checklist to help you make sure you bring all the documents you need to
your meeting with us.

Applicant’s partner’s copy

Applicant’s partner
I have answered all the questions that apply to me and my situation.
The information I have given you is true and complete.
I understand what you do with my personal information and how you protect my privacy.
Applicant’s partner’s name (print) Applicant’s partner’s signature Date

Day Month Year

Please use the document checklist to help you make sure you bring all the documents you need to
your meeting with us.

Page 24 M12 – Nov 2020