Ministry of Social Development - Confirming your Circumstances

CLIENT NUMBER
358-324-096

Bodeene Kay Maata Sullivan

1120/22 Nelson Street
Auckland Central Please return this form to:
Auckland 1010
Centralised Services Ellerslie Unit
PO Box 11593
Ellerslie, Auckland 1542

Please fill out all the questions on this form as they apply to you.

If any of the questions don't apply to you, write "nil".

Getting the information to us on time

You'll need to get your completed form to us by 22 August 2023 or your payments may be delayed.

If you need any help completing this form, call us as soon as possible on 0800 559 009 or if you're aged 65 or over, call us on
0800 552 002 so we can help.

Address 1. Has your address changed?

Give your house number, No Go to Question 2. Yes Give your new address below:
street, suburb and your
town or city.

2. Who do you live with?

First Name Surname Relationship to you

3. What is your contact telephone number?

Partner 4. Do you have a partner?

A partner is your spouse No - Are you: Single Living apart / separated Divorced
(husband or wife), your civil
union partner, or a person Widowed Civil Union dissolved
of the same or opposite sex
with whom you have a
de facto relationship Yes - Are you: Married In a Civil Union In a relationship

Please contact us if your relationship status has changed

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 CLIENT NUMBER
358-324-096

Working 5. Are you and/or your partner (if you have one) in employment?

Paid employment includes No Go to Question 7 Yes Please give details of who you are working for below
employment for which you
receive non monetary You
benefits e.g. free board Your partner

Give gross (before tax is 6. How much is your and/or your partner’s gross weekly wage?
taken out) amount of wages
and the value of any non You $ Your partner $
monetary benefits received
e.g. free board
7. Have you or your partner arranged to start work?
• You may be required to No Go to Question 8 Yes Please give details below:
provide verification

Date you start Date your partner starts

work work
Day Month Year Day Month Year

Give the name, telephone Name, address and telephone number of employer:
number and address of the
firm or person. You
Your partner

Other Income
Examples of income from
other sources:
• Wages or Salary
• Termination pay 8. Do you or your partner (if you have one) expect to get money (other than from NZ
• Redundancy pay
• Accident compensation (e.g. Superannuation or benefit) over the next 52 weeks?
ACC)
• Income Insurance (replacement / No Go to Question 9. Yes Please give details below:
protection)
• Farm or business income Where will it come from? You Your partner Jointly
• Payments from self-employment
or contract work $ $ $
• Interest from savings,
investments or bonds $ $ $
• Dividends from shares, unit
trusts or managed funds $ $ $
• Income from rents
• Payments from Boarders or
flatmates $ $ $
• Child Support payments
• Other Income for a child $ $ $
• Maintenance payments
• Payments from a former partner $ $ $
• Student Allowance, scholarship
or Student Loan living costs $ $ $
payments
• Overseas pension, benefit or $ $ $
allowance payments
• Other superannuation or $ $ $
retirement scheme income
(government or private)
• Income from an estate, if you
$ $ $
have inherited any money
• Income from trusts $ $ $
• Other
$ $ $

Please give gross (before

tax) income.

• You may be required to

provide verification

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 CLIENT NUMBER
358-324-096

Assets 9. Do you or your partner (if you have one) have any cash assets?
Examples of cash assets: No Go to Question 10. Yes Please give details below:
• money in a bank or savings Type of Asset You Your partner Jointly owned
organisation
• money lent to other people or $ $ $
organisations
• money in Bonus Bonds, $ $ $
shares, debentures or
government stock $ $ $

Examples of non-cash 10. Do you or your partner (if you have one) have any non cash assets?
assets:
• leisure boats No Go to Question 11. Yes Please give details below:
• caravans
• land or buildings other than Type of Asset You Your partner Jointly owned
your home, e.g. holiday homes
$ $ $
$ $ $
$ $ $
You may be required to 11. Do you or your partner (if you have one) have a family trust?
show proof of these details.
No Go to next section. Yes Please give details below:
Details You Your partner Jointly owned

$ $ $
$ $ $
$ $ $

Accommodation 12. Are you: renting? Go to question 13

Supplement boarding? Go to question 14
Details a home owner? Go to question 16

13. Do you pay rent for a property owned or managed by Housing New Zealand?

No Go to Question 14. Yes You are not entitled to Accommodation Supplement.

Evidence of payments may
be requested.
Please go to next section.
14. How much do you pay each week for you and your family? rent board
$ $
15. What is the name and address of your landlord?

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 CLIENT NUMBER
358-324-096

16. If you own your own home please give details below:

How often is payment?

Amount of (weekly, monthly, 2 monthly, 6
Name of company payment monthly, yearly, etc.)

Mortgage Payments $
Home Insurance $
Include both interest and Mortgage Protection $
principal. Payments / or life
Do not include contents Insurance
insurance. (when compulsory)
Please attach all your
receipts. Rates (include water $
rates)

Have you received a Rates Rebate?

No Go to Next Section. Yes

Rebate Amount:
Rating year (1 July) 20 ____
To (30 June) 20 ____ $

17. What were the total repairs and maintenance payments in the last 12
months? $

Statement The information I have given on the Ministry of Social Development -

Confirming your Circumstances form is true and I have not left anything out.
This information is required
under the Social Security Please sign here
Act 2018.

Day Month Year

Office Use Decision

Only Continue AT $ Per week FROM TO

Cancel FROM

Letter Reference Processing Officer

Day Month Year

Team Coach
Day Month Year

Bring up File

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