Unemployment Benefit Student Hardship

8/8/2019 Unemployment Benefit Student Hardship

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Find the best way to fnance your uture

.stu . t. z

UNEMPLOYMENT BENEFITSTUDENT HARDSHIPAPPLICATION FORMTo geT The UnemploymenT BenefiT STUdenT hardShip yoU mUST:

be registered for work with Student Job Search (or if theres not a Student Job Search in your region, a Work andIncome service centre) and

be actively looking for full-time workand

intend to study full-time after your study breakand

have received or will receive the Student Allowance. If youre in hardship and you dont qualify for the StudentAllowance you may still be able to get the Unemployment Bene t Student Hardship. Youll also need to completethe Additional Hardship application form on pages 10 and 11.

You will have a stand-down, or waiting time, from when you qualify for the Unemployment Bene t Student Hardship,until the time you are entitled to your bene t. You wont get paid during this stand-down.

If you have a partner or a child and youre in hardship because your Student Allowance has stopped and youre waitingfor your Unemployment Bene t Student Hardship to start, you may be able to get the Student Allowance TransferGrant. You can apply for this by answering question 1 on page 12.

If you have not been in previous study or you are 1617 years old and getting a Student Allowance your applicationmay be processed as an Emergency Bene t. If this happens, you will get the same amount as you would have received ifyou got Unemployment Bene t Student Hardship.

in ThiS applicaTion, yoU can alSo apply for:

Additional Hardship (Part 3)

Extra Help (Part 4)Student Allowance Transfer GrantAccommodation SupplementDisability AllowanceTemporary Additional Support.

From November 2010 you will be able to apply online at our website.stu . t. z . You can also check outthe application process and nd out what documents you may need to provide.

If you didnt receive a Student Allowance previously, youll need to apply for one before we can nish processing yourapplication for Unemployment Bene t Student Hardship.

The best time to apply for your Unemployment Bene t Student Hardship is at the same time you apply for your StudentAllowance or Student Loan.

yoU can poST yoUr compleTed applicaTion and verified docUmenTS To:

StudyLink Student Support CentreFreepost 113907Private Bag 11070Palmerston North 4442.


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BEFORE YOU START READ THIS PAgEhere are Some imporTanT ThingS yoU need To know Before yoU compleTe yoUr applicaTion.

y u t s s s ss b . i u t t 7 s t u u s s u u

ss ut s ts.

USe BlUe or Black ink only

When completing your application you must only use blue or black ink. If your application has been completed in any othercolour we might get you to complete another one.

anSwer all The qUeSTionS

Its important to answer every question in your application. If a question doesnt apply to you, use N/A or nil. Dont leavespace blank as this could delay the process and you may not get paid on time.

yoU will need To provide docUmenTS

When you apply for the Unemployment Bene t Student Hardship, you will need to provide at least one form of identi cation,such as a drivers licence or student ID card. You may need to provide certain other documents with your application theseare listed on page 1.

If youre providing a copy of an original document it needs to be veri ed. Af is a copy of the original documentwhich has been signed and dated by someone like a StudyLink or Work and Income staff member, of cer of a tertiaryeducation provider, school principal, Solicitor/Lawyer, Notary Public, Court Registrar or Justice of the Peace (listed in the YellowPages) who can con rm that the copy is the same as the original. They must print their name and title on the copy and writthat it is a true copy and sign it. If you send an original document we will return it by courier.

Sign and daTe The orm

r b t s t t s t 29 su s s t s t s s .

y u t s t s t t s t t , 26.


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UnemploymenT BenefiT STUdenT hardShip applicaTion form page 1

STUDENTS AND PARTNERS CHECkLISTDOCUMENTS TO PROvIDEIf youre providing a copy of an original document it needs to be veri ed. Af is a copyof the original document which has been signed and dated by someone like a StudyLink or Work andIncome staff member, of cer of a tertiary education provider, school principal, Solicitor/Lawyer, NotaryPublic, Court Registrar or Justice of the Peace (listed in the Yellow Pages) who can con rm that thecopy is the same as the original. They must print their name and title on the copy and write that it is atrue copy and sign it. If you send an original document we will return it to you by courier.yoU need To provide The following docUmenTS:e t u :

o t id (u ss u Stu t l t Stu l ). , u s c u t S s c

w tt t s t u t t s t u u t s 16 17, t u t

If you are applying for the rst time and StudyLink hasnt seen them before:

Your birth certi cate or passport.

Evidence of your immigration status if you were not born here. For example, your passport,residency documents, certi cate of citizenship or letter from Immigration New Zealand.

Evidence of any name change youve had if the name youre applying under is different fromthe name in the documents youre providing. For example, marriage certi cate or deed pollpapers.

Evidence of your IRD number. For example, your IRD card or a notice or statement from InlandRevenue.

Full birth certi cates for any children in your care.

Evidence of your bank account. For example, a pre-printed deposit slip or statement with yourname, bank, branch and account number.

i If you have been or are currently working:

We may ask for evidence of your income. For example, your last payslip or letter from youremployer.

ot i , u s s

We may ask for evidence of any other income or cash assets. For example, a bank statement orletter from your bank showing your interest from investments or savings, or the net equity inany property or land not used as your home.

We may ask for evidence of any overseas pension or income.

t a t Su t

Evidence of the regular payments you make for your home. For example, letters or statementsshowing these payments.

Evidence of your necessary repairs and maintenance carried out in the last year. For example,receipts or a bank statement showing these payments.

t d s b t a

Evidence of payments you make because of this disability.

Disability Certi cate from your General Practitioner or Specialist.

T a t Su t

Certi cate of Entitlement from Inland Revenue.

Evidence of any employment related costs you have listed.

Evidence of any essential credit sales items you have listed.

office USe onlyEvidence Received

Y / NStudent Partner


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page 2 UnemploymenT BenefiT STUdenT hardShip applicaTion form

PART 1: PERSONAL DETAILSThe docUmenTS we need To See are liSTed on page 1. yoU will need To provide aT leaST one orm oidenTi icaTion, SUch aS a driverS licence or STUdenT id card.

ThiS SecTion TellS US aBoUT yoU. yoU mUST compleTe ThiS.

1. w t s u ?

st m (s) Su

2. w t s u s s u b t t f t ? (i t b )

st m (s) Su

3. a u b u t t us t (s)?

Yes No

i s, s us u t (s):

st m (s) Su m

?y s/n

4. w t s u t b t ?

Day Month Year

we need To See an original or veri ied copy o yoUr BirTh cerTi icaTe or paSSporT (UnleSS STUdylinkhaS already Seen iT).

5. a u:

Male Female

6. w t s u t u b ?This is a number issued to you by StudyLink or Work and Income. This is on your Community Services Card if you have on

you dont have a client number or dont know it, leave this question blank.

y u t t us t s u s s tu t b us t u t u ts.

7. w u tt t U t B ft Stu t h s ?

t/h us . St t ss

Subu b c t


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7 . w u u u t b s t t t ?

Yes No (Go to Q8)

i s, s us t s ss Please note, this must be a New Zealand address.

p st ss

Subu b c t c u t

New ZealaNd

8. h t t u?When we have completed processing your Unemployment Bene t Student Hardship application we will call you to letyou know the outcome.

p m b 1 e 1

9. w u b n Z ?

Yes (Go to Q10) No

9 . w u b ?

9b. a u :

Permanent resident2 Protected person3 New Zealand citizen

Other (eg. Refugee)

i u t s t n Z t z , u t s / t z s ?

Day Month Year

we need To See an original or veri ied copy o yoUr BirTh cerTi icaTe, paSSporT or leTTer romimmigraTion new Zealand To prove yoUr reSidence (UnleSS STUdylink haS already Seen iT).

9 . i u t s t, u t t s u s s s ?

Yes No

9 . w u t n Z t ?

Day Month Year

10. d u usu n Z ?

Yes No (Its unlikely your application will be approved call us on0800 88 99 00 to discuss this)

11. w t s u ird u b ? If you have an IRD number with less than nine digits, please insert zero(s) in front of your IRD number. If you dont have oyou need to get one from Inland Revenue by calling0800 22 77 74 , or you can download a form at. . t. z .

we need To See evidence o yoUr ird nUmBer or example, an original or veri ied copy o yoUr irdcard or a STaTemenT rom inland revenUe (UnleSS STUdylink haS already Seen iT).1 If you give us your mobile number or email address we may use these to send you text messages or emails. These messages will not contain personal

information. We may use them to let you know about important changes or that its time to reapply if youre continuing with your studies.2 Australian citizens are exempt from having to hold a permit in order to reside in New Zealand. If you are an Australian citizen please choose Permanent

resident status.3 As de ned under sections 130 and 131 of the Immigration Act 2009. The Act takes effect on 29 November 2010.


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12. p s us u b u t t s s u (t s u t ust b u ):

a u t s :

Bank Branch Account Suf x

Please note if you give us an incorrect bank account number we cant pay you, please check it against your bank statement

we need To See evidence o ThiS accoUnT. evidence coUld Be an original or veri ied copy o apre-prinTed depoSiT Slip or STaTemenT wiTh yoUr name, Bank, Branch and accoUnT nUmBer (UnleSSSTUdylink haS already Seen iT).

13. T t s st t st u s s. its u t u t u s t su st . w t t u u t t t u (s) u b t .

NZ Pa keha /European Other European NZ Ma ori Samoan Cook Island Ma ori

Tongan Niuean Tokelauan Fijian Paci c Island other

Southeast Asian Chinese Indian Asian other Middle Eastern

Latin American African Other (please provide details)

i u nZ m , u b t ?

o u st t tt t U t B ft Stu t h s u t t us b ut s s su u tt t t ts.

yoU mUST call US on 0800 88 99 00 if yoU or yoUr parTner:

start getting income or your income changes

change address, phone or email address

start or nish a relationship

change bank accounts

go, or intend to go overseas.

rememBer To read yoUr oBligaTionS (inclUding The privacy STaTemenT on page 27), Then Sign anddaTe yoUr declaraTion on page 29.


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PART 2: UNEMPLOYMENT BENEFIT STUDENT HARDSHIP n b 2010 u b b t u U t B ft Stu t h s t u

bs t .stu . t. z. y u s ut t t ss f ut t u tsu t .

ThiS SecTion TellS US aBoUT yoUr circUmSTanceS. yoU mUST compleTe ThiS.

1. a u b u -t u u stu b ? Full-time work is paid work for 30 hours or more a week. This includes temporary or casual employment.

Yes No (Please call us on0800 88 99 00 to discuss your application)

2. w t t u b b u -t ?

Your payments may be calculated from this date so you need to tell us the actual date you were (or will be) available for w

Day Month Year

3. a u st t Stu t J b S w i t f u -t ? You can register with Student Job Search online at.sjs. . z or phone them on0800 75 75 62 .

Yes No (Go to Q4)

3 . w t s u Stu t J b S nu b ?

4. d u t t stu u -t t u b ?

Yes No (Please call us on0800 88 99 00 to discuss this)

i s, s u u s st t?

Day Month Year

5. h u t s u s ?

Yes No

6. h u Stu t a u t u s ?

Yes No (If you didnt get a Student Allowance for the course you just nished, youll also need to complete the Additional Hardship application form on page 10)

i u t u Stu t a t u t t s s s s ss b . T s st t t s s us m Stu l u t t .stu . t. z

7. d u t ?

For the Unemployment Bene t Student Hardship, a partner is your spouse, civil union partner, or someone of the same oropposite sex with whom you have a de facto relationship.If your partner is 16 or 17 years old, they can be included in yourbene t if you are married, in a civil union or have a dependent child. If you are in a de facto relationship where you or youpartner is aged 16 or 17 years old and neither of you have a dependent child, the parents or guardians of the 16 or 17 yearmust give their consent for the de facto relationship.

Yes (Go to Q7a) No (Go to Q7c)

If yes, your partner must complete the Partners form on page 20.


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7 . a u: Married In a de facto relationship In a civil union

7b. w t s t t u u t t s st tus st t ?

Day Month Year

(Go to Q8)

7 . a u:

Single Living apart or separated Divorced Widowed

8. i u u 20 s u t u t(s) u (s)?

Yes No Im not under 20 years old

i u u u w s T c ts i r u . T f ut t t i r u 0800 22 77 73.

9. d u u ?By children we mean anyone under 18 who lives with you and who you are primarily responsible for providing the care and

nancial support for this includes stepchildren, children at boarding school, adopted or whangai children, grandchildrenor mokopuna. It doesnt include children who are supporting themselves or working full-time, or anyone you are being paida Work and Income Orphans or Unsupported Childs bene t, or a Child, Youth and Family payment for. Please note: thisde nition is different from that of the Student Allowance.

Yes (Go to Q9a) No (Go to Q10)

i s, s us t t s:

c s u g ( / ) d t b t

00 / 00 0 / 0000 / 00 0 / 00

00 / 00 0 / 00

00 / 00 0 / 00

9 . w u s ust t b u u stu b ?

Yes No (Go to Q10)

i s, s us t s t ust t:

c s u d s t t ot ust s ot ust s ss

y u u b b t c Subs out S c r t Subs (oScar). t s t u bs t .stu . t. z

we need To See an original or a veri ied copy o each childS Ull BirTh cerTi icaTe (UnleSS STUdylinkhaS already Seen Them).


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10. d u u t ss ts?This could be money in a bank or savings account including term deposits, money lent to other people or organisations, moneyin Bonus Bonds, shares, debentures or Government stocks, leisure boats, caravans, land or buildings other than your home (forexample a holiday home).

Yes No (Go to Q11)

i s, s us t s u ss ts:

T ss t o ss t( u, u t b t ) v um ( )

$ $

$ $

$ $

$ $

we may aSk or evidence o yoUr aSSeTS.

T u , u s ss ts ust b u t ts. T f ut t t s , s t u bs t.stu . t. z

i u u t u t t us b t t u t ut u u b u t t b . w u t t t t s

.

11. a u ?

Yes No (Go to Q12)

11 . is t j b: Full-time Part-time Voluntary Self-employment Casual

11b. w u st t t s j b?

Day Month Year

11 . p s us t s u b t : By per week we mean from each Monday to the following Sunday.

w b t h u s e s s u

$

$

e s t ( t) Bus ss ss Subu b / c t / T

1.

2.

we may aSk or evidence o yoUr income.

12. h u b t t t t st 6 t s? Paid work also includes any indirect monetary bene ts such as free board or shares in a business.

Yes No (Go to Q13)

12 . w u st t t s j b?

Day Month Year


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12b. w u t s j b ?

d t u t st j b r s t s j b

Day Month Year

12 . d u t , u t t -t t st 26 52 s? Yes No (Go to Q13)

i s, s t:

l st 26 s l st 52 s

$ $

$ $

$ $

we may aSk or evidence o ThiS paymenT.

13. d u t t ? Income is any money you or your partner get from any source, taxable or non-taxable. This could include but is not limitedto wages, salary, termination payment, bonus pay, holiday pay, child support, maintenance payments, paid parental leave,interest from savings and investments, dividends from shares, income from a family trust, farm or business, income fromboarders or rent, superannuation, overseas bene ts and pensions, weekly accident insurance payments, some scholarships,any indirect monetary bene ts you get such as free board or shares in a business, and any other income that you have or maydeprive yourself of.

Note for Temporary Additional Support assistance the following are also considered income: Student Allowances, the livingcosts component of the Student Loan, Working for Families tax credits, all Work and Income bene ts except UnsupportedChilds Bene t and Orphans Bene t.

Yes No (Go to Q14)

i s, s us t s u b t ?

T w b t

$

$

r b t u su t ts u t s but t u u Stu ta , Stu t l T c ts.


14. w t s u b t t st 26 52 s? For example, to calculate your average weekly income for the last 26 weeks, take your total income over the last 26 weeks adivide by 26 (remember to include any current income). If you had no income write $0 or NIL.

l st 26 s l st 52 s

$ $

we may aSk or evidence o ThiS income.

15. w t t s u s u t ss t ?Help from parents Student Loan Savings None

Other (please explain)

Holiday pay how much before tax?

Redundancy pay how much before tax?

Termination pay how much before tax?


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16. h u s s? This could include working holidays where you have paid tax to an overseas government, places where you have had a homeand resided, or if you have lived in another country with a member of your family (who was working overseas). Lived doesnot mean recreational holidays or where you have lived and been based in New Zealand but you travelled overseas to work foa short period and you paid New Zealand tax on those earnings.

Yes No

i s, s us t s u t s s: n u t e t t e t t pu s ( . . , t )

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / / / / / /

17. d u t s s s s u t s b ft ( s t s st)?

Yes No

i s, s t t(s):

Retirement or old age Disability or invalidity Widow or survivor War service

War widow War restitution Superannuation Child or dependant

War injury Other payments (please explain)

17 . p s us t s t s t(s):

n u s ,b ft t t(s)

c u t ts

a u t (s s

u )B

t t ?h t

u ?o s s

t .


i u u st s b ut s s b fts s s w i s i t t S s:

i u : c i t t S s :

Australia 0800 777 227

United Kingdom 0800 771 001Jersey 0800 771 001Guernsey 0800 771 001Republic of Ireland 0800 771 001Any other country 0800 777 117

rememBer To read yoUr oBligaTionS (inclUding The privacy STaTemenT on page 27), Then Sign and daTeyoUr declaraTion on page 29.


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PART 3: UNEMPLOYMENT BENEFIT STUDENT HARDSHIPADDITIONAL HARDSHIP APPLICATION FORM

compleTe ThiS SecTion if yoU donT qUalify for a STUdenT allowance and are applying for TheUnemploymenT BenefiT STUdenT hardShip BecaUSe yoUre in hardShip.

1. w t u u Stu t a ? If you dont know, take the eligibility test online at.stu . t. z or call us on0800 88 99 00 if you dont

have internet access.

2. h u su t u s u t stu ?

Student Loan living costs per week $ Scholarship(s) per week $

Work per week $ Savings Total amount $

Help from parents per week $ Overdraft Limit $

Personal loan per week $ Other (please Total amount $ explain below)

3. is t su t u st b b t u u t stu b ?

Yes No

i , s t us t:

4. w u b t u t(s) u (s) u t stu b ?

Yes No

5. c u t(s) u (s) su t u?

Yes (Go to Q6) No

i , s u ts f u st s t t b t t su t u:

6. w t sts u u t stu b ? For example, hire purchases, rental agreements.


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7. w t u t tt t t u f s tu t ?

8. is t t s u t t us b ut u s s tu t t t su t u t ? For example, your health or any family issues. Please give us a full and detailed explanation (you can continue on a separatepage if required).

we may aSk or evidence o ThiS.


r b a b d s

Signature Signature

Date Date DateTo be completed by Manager

Reason for approval or decline:

office USe only

Approved

Declined

Pending


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PART 4: EXTRA HELPTO gO WITH YOUR UNEMPLOYMENT BENEFIT STUDENT HARDSHIP

T u ts t s st 1.

aS a reTUrning STUdenT, yoU may Be eligiBle for exTra financial aSSiSTance from The miniSTryof Social developmenT if yoU are receiving an UnemploymenT BenefiT STUdenT hardShip.

its t t t t u s t u st s t s s t , s t t ss ss u u t t t tt .

1. d u t t t Stu t a T s g t? Student Allowance Transfer Grant can be paid when you are in hardship because your Student Allowance has stopped andyoure waiting for Unemployment Bene t Student Hardship to start. The Student Allowance Transfer Grant is a one-offpayment and you will only be eligible if you have a dependent partner or child.

Yes No (Go to Q2)

1 . i s, t s, b , u t t u st stu ?

T y u bty u t s b t

$ $

$ $

$ $

y u t t s t ( u b ft) b u u s f s s t t s ut ss ut ts.


2. d u t t t a t Su t? Accommodation Supplement can help with the cost of renting, boarding or owning a home. This assistance can only be paidfor the place where you are actually living.Note: if you are already getting the Accommodation Supplement then you dont need to reapply. This is different to theAccommodation Bene t paid with a Student Allowance.

Yes No (Go to Q9)

3. d u ?

Yes (Go to Q4) No

3 . i , s u t ?

st Su r t s t u

4. d u u t - s ss ts?Non-cash assets could be leisure boats, caravans, land or buildings other than your home, (for example a holiday home).

Yes No (Go to Q5)

i s, s us t t s u - s ss ts:

T ss t o ss t( u, u t b t ) v u m ( )

$ $

$ $

$ $


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5. w tt t U t B ft Stu t h s , u b :

Renting (Go to Q6) Boarding (Go to Q7) Living in a house you own (Go to Q8)

renTing compleTe ThiS qUeSTion only if yoU are renTing.

6. is t ss u us u U t B ft Stu t h s t t b h us n Z ?

Yes No (Go to Q6a)

If yes, you wont be able to get the Accommodation Supplement dont continue with this section. You may qualify forincome-related rent from Housing New Zealand instead. Go to the Housing New Zealand website:. z . t. z to fndout more, or phone your local Housing New Zealand Neighbourhood Unit youll nd their number on the website or in yourphone book. (Go to Q9)

6 . w t s t t t t t t ? $

6b. h u t t u u s u ? $

6 . w u t t ?

n a ss p

we may aSk or evidence o yoUr renT or example a renT Book or Tenancy agreemenT.

Boarding compleTe ThiS qUeSTion only i yoU are Boarding.

7. h u b u ( u u )? $Include all expenses such as power, phone and food.

7 . w u b t ?

n a ss p

we may aSk or evidence o yoUr Board or example a leTTer rom yoUr landlord.

own home compleTe ThiS qUeSTion only if yoU live in a hoUSe yoU own.

8. p s us t s t ts u u :

n h t u

? . . ,t t , t

a u t

First mortgage $Second mortgage $Ground lease $Mortgage insurance $House insurance(not including contents) $Rates (including water) $

we need evidence o all The paymenTS yoU make or yoUr home or example, an original or veri iedcopy o a Bank STaTemenT Showing yoUr paymenTS (UnleSS STUdylink haS already Seen iT).

8 . h u t s b t ?

No Yes Amount $ Rating Year (1 July) 20___ to (30 June) 20__ _

8b. w t s t t t st ss s t t st ? $

we need To See original or veri ied copieS o receipTS.

8 . i u h us n Z t , t s u t st t ? %


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1 A partner is your spouse, civil union partner, or someone of the same or opposite sex with whom you have a de facto relationship.

9. d u t t d s b t a ?Note: if you are already getting the Disability Allowance then you dont need to reapply. If you, or a family member, have anillness or disability, which is likely to continue for at least six months, you may be able to get extra help through a DisabilityAllowance. We may be able to help with costs including but not limited to ongoing visits to the doctor, medicines, medicalalarms and travel. Your doctor or specialist will need to complete the Disability Certi cate on page 15.

Yes No (Go to Q14 on page 17)

10. w u ?You can apply for a Disability Allowance for each member of your immediate family including your partner1 or child. If you wishto apply for a Disability Allowance for more than one person you will need your doctor or specialist to complete a separateDisability Certi cate for each person. (You can photocopy the certi cate on pages 15 and 16 if you need more than one.)

Yourself (Go to Q11) Your partner Your dependent child (Please give their full name below) (Please give their full name below)

st Su r t s t u

i u d s b t a t , u u s cd s b t a . t s t .stu . t. z

11. is t s b t b t su ?

No Yes(Please give the name of the insurance company and the person it applies to below)

12. is t s b t b acc w d s b t p s ?

No Yes (You may not be entitled to a Disability Allowance)

13. w t t s s u s su t t ss s b t ?All of these expenses must be directly related to the illness or disability and veri ed as necessary by a registered healthprofessional.

e sh t u ? . .

, t t , t

a u t

w s st s t?( . . u s ,

u t , ut )

$$$$$$$$

we need evidence o all The paymenTS yoU make BecaUSe o ThiS diSaBiliTy or example, invoiceS,receipTS, qUoTeS or prinToUTS or each addiTional expenSe.


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clienT nUmBer Bene iT Type

DISABILITY CERTIFICATE

general pracTiTioner or SpecialiST To compleTe:

1. w t s t ts ?

st m (s) Su

t b ut d s b t a t t gu m p t t s d s b ta b u .

The Disability Allowance is available for reimbursement of additional costs arising from an illness or disability where thefollowing criteria is met:1. The person has an illness or disability which is likely to continue for not less than six months; and2. The illness or disability has resulted in a reduction of the persons independent function to the extent that:

The person requires ongoing support to undertake the normal functions of life, or

The person requires ongoing supervision or treatment by a health practitioner.For the purposes of qualifying for Disability Allowance, a disability means:

physical disability or impairment physical illness psychiatric illness intellectual or psychological disability or impairment any other loss or abnormality of psychological, physiological, or anatomical structure or function (including sensory

impairment) reliance on a guide dog, wheelchair, or other remedial means the presence in the body of organisms capable of causing illness.

2. d t s s sts ss:

d t s sts a ss p

3. d s t s s b t t t ts t d s b t a t b ?

Yes No (Go to Q8)

4. w t s t tu t s s s b t ?Please tick the major disabilities or specify below:

Psychological or psychiatric conditions

Stress (160)

Depression (161)

Bipolar disorder (162)

Schizophrenia (163)

Other psychological/psychiatric conditions (165)

Nervous system disorders

Epilepsy (120)

Multiple sclerosis (121)

Parkinsons disease (122)

Muscular dystrophy (123)

Other nervous system disorders (124)

Cardio-vascular disorders

Heart disease (130)

Stroke (131)

Other cardio-vascular disorders (132)

Immune system disorders

HIV / Aids (140)

Other immune system disorders (141)

Metabolic and endocrine disorders

Diabetes (150)

Other metabolic or endocrine disorders (151)

continued over page ...


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Substance Abuse

Alcohol (170)

Drug (171)

Other substance abuse (172)

Sensory disordersBlindness (180)

Other visual / eye (181)

Hearing / ear (182)

Other sensory disorders (183)

Accident

Burns (190)

Fractures, dislocations, soft tissue injury (191)

Poisoning, toxic effects (192)

Internal injuries (193)

Injury to the nervous system (194)

Back pain / injury (195)

Overuse injury [RSI] (196)

Complications of medical or surgical care (197)

Other injury (198)

Other disorders

Congenital conditions (103)

Intellectual disability (164)

Cancer (104)

Infectious / parasitic diseases (105)

Musculo-skeletal system disorder (106)

Respiratory disorders (107)

Genito-urinary disorders (108)

Blood and blood forming organs (109)Skin disorders (110)

Digestive system disorder (111)

Other (please explain below)

5. p s t t t u t t s b t

less than 6 months (there may be no entitlement to Disability Allowance)

6 to 12 months 1 to 2 years 2 to 3 years Permanent (never reassess)

6. p s st t t , st u s ts t t t s s sts t t ss su t t st t s b t :

T su t t c st u gp / S st t s

$

$

$

$

7. p s st t ut s, t s, s s t t ts t t ss t ut u t st t s b t :

it / S / T t t / p ut gp / S st t s

8. r st m p t t v f t

Registered Medical Practitioners stamp: Medical Council registration number:

Day Month Year

Medical Practitioners signatureThis in ormation is required under the Social Security Act 1964.

Privacy Act: The person has been advised and understands that thisin ormation is required or beneft assessment purposes.


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14. d u t t T a t Su t?Note: if you are already getting Temporary Additional Support then you dont need to reapply. If you are nding it hard

nancially, extra help with essential costs may be available through Temporary Additional Support. Its important that youtake all necessary steps to get other assistance towards costs and take reasonable steps to increase income and reduce costswhere possible. Your assets will need to be below a certain level to qualify. We may also need to contact you to arrange aappointment to discuss your eligibility with someone in person.

Yes No (Go to Partners Form on page 20)

15. d u / u t w s T c ts i r u ?Working for Families Tax Credits include: family tax credit, in-work payment, minimum family tax credit, child tax credit,parental tax credit.

Yes (Please give details below and provide a Certi cate of Entitlement from Inland Revenue) No

y u y u t h t ( , t t t )

$ $

y u t c t f t e t t t b i r u 0800 257 720. p s u ird

u b .

we need To See an original or veri ied copy o a cerTi icaTe o enTiTlemenT rom inland revenUe.

16. d u / u t ss t t sts?Employment costs include: vehicle running costs or public transport to employment, childcare if the caregiver is working, and atelephone if it is a condition of employment.

Yes (Please provide details below and provide proof of these costs) No

e t st a u t h t ( ,t t t )

$$

$

we need To See original or veri ied copieS o TheSe employmenT coSTS.

17. d u / u t ss t t s s ( u s s) u sts?Essential items that may be included: beds, dining suites, fridge/freezer, portable heaters, lounge suite, stove, television, vehiclerepayments, washing machine (or laundrette costs), dryer (disability) and childcare costs (disability).

Yes (Please provide details below and provide proof of these costs) No (Go to Q18)

it a u t h t ( ,t t t ) St t / u s t e t

$ / / /$ / / /$ / / /$ / / /$ / / /$ / / /$ / / /$ / / /

Please talk to us if you, your partner or any dependent children have disability costs but have not applied for a Disability Allowance.

we need To See original or veri ied copieS o TheSe coSTS. i They are a conSUmer crediT Sale (hirepUrchaSe) we will need To See yoUr original pUrchaSe agreemenT and The laTeST Balance STaTemenT.


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17 . Tell us your reasons for purchasing the items you listed in Q17 and whether they are on a consumer credit contract(this is an agreement for a xed payment amount over a xed period of time) or revolving credit (such as a creditcard or shop card).

We need to know that the cost was essential to meet your familys daily living needs and could not be readilyavoided or varied when the expense occurred.

it r s u sc su t(cc)

t (rc)

i yoU pUrchaSed yoUr iTem on a revolving crediT paymenT we will alSo need To See evidence o yoUrBalance prior To The pUrchaSe.

18. d u / u t t s t s u t s s, b us s u st s?

Telephone costs for personal safety or security need to be veri ed by either the police, court orders, womens refuge, previoushistory held by Work and Income, Child, Youth and Family or any other relevant organisation.

Yes (Please provide details below) No (Go to Q19)

d t s u st s

Amount $ How often (weekly, fortnightly etc)

we need evidence o yoUr circUmSTanceS and yoUr Telephone renTal coST (exclUding Toll or callchargeS and moBile phoneS) i we donT have TheSe deTailS already.


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19. p s t t st s u / u t t , t , t t t ss st , usts s .

Temporary Additional Support is last resort nancial assistance, you and your partner must take all necessary steps to get otherassistance towards costs and take reasonable steps to increase income and reduce costs where possible.

We may need to talk with you about what other steps you might be able to take.



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PART 5: PARTNERS FORMThiS SecTion iS To Be compleTed By The parTner of The perSon applying for The UnemploymenTBenefiT STUdenT hardShip.

T u ts t s st 1. y u t t st t f t , su s s .

1. w t s u ?

st m (s) Su

2. w t s u s s u b t t f t ? (i t b )

st m (s) Su

3. a u b u us t (s)?

Yes No (Go to Q4)i s, s us u t (s):

st m (s) Su m

?y s/n

4. w t s u t b t ?

Day Month Year

we need To See an original or veri ied copy o yoUr BirTh cerTi icaTe or paSSporT (UnleSS STUdylinkhaS already Seen iT).

5. a u:

Male Female

6. w t s u t u b ?This is a number issued to you by StudyLink or Work and Income. This is on your Community Services Card if you have onyou dont have a client number or dont know it, leave this question blank.

7. d u t t stu t?

Yes (Go to Q7a) No

i , u ?

t/h us . St t ss

Subu b c t

7 . a u ( u b ) t b h us n Z ? Yes No

y u t t us t s u s s tu t b us t u t u ts.


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8. h t t u?

p m b e

9. w u b n Z ?

Yes (Go to Q10) No

9 . w u b ?

9b. a u :

Permanent resident1 Protected person2 New Zealand citizen

Other (eg. Refugee)

i u t s t n Z t z , u t s / t z s ?

Day Month Year

we need To See an original or veri ied copy o yoUr BirTh cerTi icaTe, paSSporT or leTTer romimmigraTion new Zealand To prove yoUr reSidence (UnleSS STUdylink haS already Seen iT).

9 . i u t s t, u t t s u s s s ?

Yes No

9 . w u t n Z t ?

Day Month Year

10. d u usu n Z ?

Yes No

11. w t s u ird u b ? If you have an IRD number with less than nine digits, please insert zero(s) in front of your IRD number. If you dont have oyou need to get one from Inland Revenue by calling0800 22 77 74 , or you can download a form at. . t. z .

we need To See evidence o yoUr ird nUmBer or example, an original or veri ied copy o yoUr irdcard or a STaTemenT rom inland revenUe (UnleSS STUdylink haS already Seen iT).

12. p s us u b u t t s s ut u t t U t B ft Stu th s t t s u t. T s u t ust b u . i u u t b t s

s s u t s t a t t a t . y u t.stu . t. z.

a u t s :

Bank Branch Account Suf x

Please note if you give us an incorrect bank account number we cant pay you, please check it against your bank statement

we need To See evidence o ThiS accoUnT. evidence coUld Be an original or veri ied copy o a pre-prinTed depoSiT Slip or STaTemenT wiTh yoUr name, Bank, Branch and accoUnT nUmBer (UnleSSSTUdylink haS already Seen iT). 1 Australian citizens are exempt from having to hold a permit in order to reside in New Zealand. If you are an Australian citizen please choose Permanent

resident status.2 As de ned under sections 130 and 131 of the Immigration Act 2009. The Act takes effect on 29 November 2010.


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13. T t s st t st u s s. its u t u t u s t su st . w t t u u t t t u (s) u b t .

NZ Pa keha /European Other European NZ Ma ori Samoan Cook Island Ma ori

Tongan Niuean Tokelauan Fijian Paci c Island other

Southeast Asian Chinese Indian Asian other Middle Eastern

Latin American African Other (please give details)

i u nZ m , u b t ?

14. d u u 6?

Yes (Go to Q16) No

14 . i , u ( u b ) b ?

Day Month Year

14b. a u st t Stu t J b S ( u t t t s u t stu t), w i t f ?

Yes No (Go to Q16)

14 . i u st t Stu t J b S , t s u Stu t J b S nu b ?

15. a u stu u t t stu t t ?

Yes No

15 . i s, / s u u s st t?

Day Month Year

If you havent applied for a Student Allowance or Student Loan you can apply online at.stu . t. z .

16. a u ?

Yes No (Go to Q17)

16 . is t j b:

Full-time Part-time Voluntary Self-employment Casual

16b. w u st t t s j b?

Day Month Year

16 . p s us t s u b t :By per week we mean from each Monday to the following Sunday.

w b t h u s e s s u

$

$

e s t ( t) Bus ss ss Subu b / c t / T

1. 2.



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17. h u b t t t t st 6 t s?

Paid work also includes any indirect monetary bene ts such as free board or shares in a business.

Yes (Go to Q17a) No (Go to Q17c)

17 . w u st t t s j b?

Day Month Year

17b. w u t s j b ?

d t u t st j b r s t s j b

Day Month Year

17 . d u t , u t t -t t st 26 52 s?

Yes No (Go to Q18)

i s, s t:

l st 26 s l st 52 s

$ $

$ $

$ $

we may aSk or evidence o ThiS paymenT.

18. d u t t ? Income is any money you or your partner get from any source, taxable or non-taxable. This could include but is not limitedto wages, salary, termination payment, bonus pay, holiday pay, child support, maintenance payments, paid parental leave,interest from savings and investments, dividends from shares, income from a family trust, farm or business, income from

boarders or rent, superannuation, overseas bene ts and pensions, weekly accident insurance payments, some scholarships,any indirect monetary bene ts you get such as free board or shares in a business, and any other income that you have or maydeprive yourself of.Note for Temporary Additional Support assistance the following are also considered income: Student Allowances, the LivingCosts component of the Student Loan, Working for Families tax credits, all Work and Income bene ts except UnsupportedChilds Bene t and Orphans Bene t.

Yes No (Go to Q19)

i s, s us t s u b t ?

T w b t

$

$


19. w t s u b t t st 26 52 s? For example, to calculate your average weekly income for the last 26 weeks, take your total income over the last 26 weeks adivide by 26 (remember to include any current income). If you had no income write $0 or NIL.

l st 26 s l st 52 s

$ $

20. w t t s u s u t ss t ?

Personal income Help from parents Student Loan Savings None

Other (please explain)


Holiday pay how much before tax?

Redundancy pay how much before tax?

Termination pay how much before tax?


26/32


21. h u s s? This could include working holidays where you have paid tax to an overseas government, places where you have had a homeand resided, or if you have lived in another country with a member of your family (who was working overseas). Lived doesnot mean recreational holidays or where you have lived and been based in New Zealand but you travelled overseas to work foa short period and you paid New Zealand tax on those earnings.

Yes No

i s, s us t s u t s s: n u t e t t e t t pu s ( . . , t )

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

22. d u t s s s s u t s b ft ( s t s s

t)? Yes No

i s, s t t(s):

Retirement or old age Disability or invalidity Widow or survivor War service

War widow War restitution Superannuation Child or dependant

War injury Other payments, please explain

21 . p s us t s t s t(s):

n u s ,b ft t t(s)

c u t ts

a u t (s s

u )B

t t ?h t

u ?o s s

t



i u u st s b ut s s b fts s s w i s i t t S s:

i u : c i t t S s :

Australia 0800 777 227

United Kingdom 0800 771 001Jersey 0800 771 001

Guernsey 0800 771 001Republic of Ireland 0800 771 001Any other country 0800 777 117


27/32


PRIvACY STATEMENTThe legislation administered by the Ministry of Social Development allows us to check the information that you give us inthis form.

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 SocialDevelopment.

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 StudyLink, Work and Income, Child Youth and Family and other service lines of the Ministry), and inparticular for: granting nancial assistance and other assistance under the Social Security Act 1964 and Education Act 1989 (and

any Regulations under those Acts) statistical and research purposes providing advice to Government care and protection needs of children

providing support and services to you and your family providing education related services providing employment related services.

Other information that you give us on your skills, aspirations, family circumstances, and that is not required to assessyour entitlement to nancial assistance may be used to provide a better service to you by the Ministry of SocialDevelopment.

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 AccidentCompensation Corporation, Housing New Zealand, Statistics New Zealand, the Ministry of Health, Immigration NewZealand, the Ministry of Education, the New Zealand Quali cations Authority, the Tertiary Education Commission,Student Job Search and education providers. 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 sharedwith 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 corrthat information.

You are not required to give us information; but if you do not give us all the information we ask for, the studentsapplication for nancial assistance may be declined.


28/32


Sign here

Partners declarationPARTNERS OBLIgATIONSWhen the student gets nancial help from us you also have obligations to meet. If you dont meet them, your and/or thestudents payments could stop and in some cases you and/or the student could be prosecuted.

h u b t s.When the student gets the Unemployment Bene t Student Hardship you (the students partner) must: be available for, and take reasonable steps to obtain suitable employmentand accept any offer of suitable employmentand attend and participate in an interview opportunity for any suitable employment to which your are referredand attend and participate in any interview with StudyLink when required toand undertake planning for employment when required by StudyLinkand take part in any other activities that StudyLink ask me to (including rehabilitation, but not medical treatment) such

as work experience, work assessments, seminars or programmes that will improve my work readiness or prospects foremployment and

let StudyLink know how I am meeting my work obligations as often as StudyLink reasonably requires.You wont have to do this if your youngest child is under 6. If your youngest child is 618 years old you need to look forpart-time work (15 hours a week or more).i t s You must tell us straight away if you: Have a change in your work situation (such as starting part-time, casual or full-time work, paid or unpaid). Intend to travel overseas. Have changes to your living situation, including:

starting or ending a relationship such as a marriage, a civil union or a de facto relationship with someone of the same or opposite sexor

separationor a change in the number of children you supportor a change in accommodation costs.

Have changes to your income or nancial circumstances.

Have changes to your personal details (such as name, address or bank account number). Become self employed or start to run a business. Are imprisoned or held in custody on remand. Are admitted to or discharged from hospital. Have been granted an overseas pension. Have any other changes that may affect whether you can get income support or how much you get (for example, if

youre no longer available for work). Start study.B st t usWhen you sign this form you are acknowledging that the information you give us is true and you have not left anythingout. You understand that your and/or the students payments may be reviewed and cancelled if you: make a false statementor

dont answer all the questions fullyor dont tell us about changes in your circumstances that could affect your (and the students) eligibility.If this happens, you understand that you and/or the student will have to pay back the total amount of any overpaymentplus collection costs, and you and/or the student may be prosecuted.

SIgN HEREPARTNERS DECLARATIONThe information I have provided is true and I have not left anything out. I have read and understood the Privacy Statementand my obligations as set out above. I understand that my payments or my partners payments may be reduced or stoppedif I make a false statement or dont tell StudyLink of a change in any circumstances, or fail to meet my obligations. If this

happens I understand that I will have to pay back any overpayments plus collection costs, and I could be prosecuted.p t s s tu

Day Month Year


29/32


PRIvACY STATEMENTThe legislation administered by the Ministry of Social Development allows us to check the information that you give us inthis form.

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 SocialDevelopment.

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 StudyLink, Work and Income, Child Youth and Family and other service lines of the Ministry), and inparticular for: granting nancial assistance and other assistance under the Social Security Act 1964 and Education Act 1989 (and

any Regulations under those Acts) statistical and research purposes providing advice to Government care and protection needs of children

providing support and services to you and your family providing education related services providing employment related services.

Other information that you give us on your skills, aspirations, family circumstances, and that is not required to assessyour entitlement to nancial assistance may be used to provide a better service to you by the Ministry of SocialDevelopment.

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 AccidentCompensation Corporation, Housing New Zealand, Statistics New Zealand, the Ministry of Health, Immigration NewZealand, the Ministry of Education, the New Zealand Quali cations Authority, the Tertiary Education Commission,Student Job Search and education providers. 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 sharedwith 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 corrthat information.

You are not required to give us information; but if you do not give us all the information we ask for, your applicationfor nancial assistance may be declined.

yoU can poST yoUr compleTed applicaTion and veri ied docUmenTS To:

StudyLink Student Support CentreFreepost 113907Private Bag 11070Palmerston North 4442.


30/32


Students declarationSTUDENTS OBLIgATIONSWhen you get nancial help from us you need to meet all your obligations. If you dont, your payments could stop and insome cases you could be prosecuted.h u b t s.When you get the Unemployment Bene t Student Hardship you agree to: be available for, and take reasonable steps to obtain suitable employmentand accept any offer of suitable employmentand attend and participate in an interview opportunity for any suitable employment to which you are referredand attend and participate in any interview with StudyLink when required toand undertake planning for employment when required to by StudyLinkand take part in any other activities that StudyLink ask me to (including rehabilitation, but not medical treatment) such

as work experience, work assessments, seminars or programmes that will improve my work readiness or prospects foremployment and

let StudyLink know how I am meeting my work obligations as often as StudyLink reasonably requires.i t s You must tell us straight away if either you or your partner: Have a change in your work situation (such as starting part-time, casual or full-time work, paid or unpaid). Intend to travel overseas. Have changes to your living situation, including:

starting or ending a marriage, a civil union or a de facto relationship with someone of the same or opposite sexor separationor a change in the number of children you supportor a change in accommodation costs.

Have changes to your income or nancial circumstances. Have changes to your personal details (such as name, address or bank account number). Become self employed or start to run a business. Are imprisoned or held in custody on remand. Are admitted to or discharged from hospital. Have been granted an overseas pension. Have any other changes that may affect whether you can get income support or how much you get (for example, if

youre no longer available for work). Start study.i t t t b b t s u t b t s t b fts u .c oScar subsIf you are paid Childcare or OSCAR subsidy, you must tell StudyLink immediately if you (or your partner): have a change in the costs of childcareor have any other changes that may affect your entitlement to Childcare/OSCAR subsidy.c d s b t aIf you are paid Child Disability Allowance, you must tell StudyLink immediately if the child or young person: is admitted to or discharged from hospitalor leaves your careor enters residential careor intends to travel overseas.You must also tell StudyLink immediately if you have any other changes that may affect entitlement to Child DisabilityAllowance. This includes any signi cant improvement in the childs disability eg the child or young person no longer requiresconstant care and attention.d s b t aIf you are paid Disability Allowance, you must tell StudyLink immediately about changes to you / your partners disabilitycosts.T a t Su tIf you are granted Temporary Additional Support, you agree that you and your partner (where applicable) must take allnecessary steps to get other assistance towards costs and take reasonable steps to increase your income and reduce costswhere possible.B st t us When you sign this form you are acknowledging that the information you give us is true and you have not left anythingout. You understand that your payments may be reviewed and cancelled if you: make a false statementor dont answer all the questions fullyor dont tell us about changes in your circumstances that could affect your (and your partners) eligibility.If this happens, you understand that you will have to pay back the total amount of any overpayment plus collection costs,and you may be prosecuted.


31/32


p ss h

Date of Application Validating IDDate of Event SignatureLoWE $ Bank AccountExpiry Date Cash Assets $AGWE $ Current Income $SJS Partner Income $Additional information:

Decision:

UBSH Granted Declined Incomplete

Additional Hardship Granted Declined Incomplete

SATG Granted Declined Incomplete

DA Granted Declined Incomplete

TAS Granted Declined Incomplete

Sign here

office USe only

p s t t s b ss :

Unemployment Bene t Student Allowance Additional Hardship Student Hardship Transfer Grant

Accommodation Supplement Disability Allowance Temporary Additional Support

p ss b aut t t b c b

Signature Signature Signature

Date Date Date

r y s n a y s n issu y s n

Signature Signature Signature

Date Date Date

Stu t a T s g t

SIgN HERESTUDENTS DECLARATIONThiS confirmS yoUr applicaTion. yoU mUST compleTe iT. The information I have provided in this application is true and I have not left anything out. I have read and understood thePrivacy Statement and my obligations as set out above. I understand that my payments may be reduced or stopped if I make

a false statement or dont tell StudyLink of a change in any circumstances or fail to meet my obligations. If this happens Iunderstand that I will have to pay back any overpayments plus collection costs, and I could be prosecuted.Stu ts s tu

Day Month Year


32/32

MyStudyLin et it all done online apply for your student nances

check your Student Allowance and Student Loan application status

view and update your personal details

check your Student Loan balance, change the amount of your living cost payments and apply

for your course-related costs view details of your next payment and previous transactions

view your mail online

view and accept your Student Loan Contract (from November 2010)

apply for Unemployment Bene t Student Hardship (from November 2010).

www.studylin . o t.nz

HOW TO CONTACT USWebsite: .stu . t. z

Phone: 0800 88 99 00

Fax:0800 88 33 88

Stu l Stu t Su t c tp st 113907

p t B 11070p st n t 4442

Documents

Unemployment Benefit Student Hardship