6 January 2023
Client number:
Mr Richard Lawson 4 0 4 4 3 2 3 0 9
C/- Kathleen Lawson
45 Dives Avenue
Hawera 4610
Kia ora Richard
IT'S TIME TO REAPPLY FOR YOUR TEMPORARY ADDITIONAL SUPPORT
If you still need help with your costs, you'll need to reapply before 3 February 2023.
These costs are used to work out your Temporary Additional Support payments:
A c c ommoda t i on Supp l emen t c o s t s $300 . 00 e v e r y we e k
THERE ARE THREE WAYS YOU CAN REAPPLY
1. The easiest and quickest way is to login to MyMSD and select reapply for Temporary
Additional Support.
2. Call us on 0800 559 009, or if you're over 65 call 0800 552 002 and say "Temporary
Additional Support".
3. Complete the reapplication form included with this letter and return it to us
If you don't reapply before 3 February 2023 your Temporary Additional Support will stop.
Payments can only start again from the date we get your reapplication.
WE'RE HERE TO HELP
If you'd like help to set up your MyMSD account, or have any questions, we're here to
help. Please feel free to get in touch or visit our website for more information. Our details
are on the back.
Everyone's situation is different, so we're always happy to talk things through with you.
Noho ora mai
Vanessa Evans
Manager Client Service Delivery
BP1 v5.0
To contact us visit www.workandincome.govt.nz/contact
Temporary Additional
Support Re-application
CLIENT NUMBER: 4 0 4 4 3 2 3 0 9
CLIENT NAME AND ADDRESS Please return form to:
Mr Richard Lawson Hawera
C/- Kathleen Lawson Service Centre
45 Dives Avenue
Hawera 4610
Your Temporary Additional Support will end on: 9 February 2023
Day Month Year
You can re-apply for Temporary Additional Support. If you do re-apply you will have to show us that you have
taken all necessary steps to get other assistance towards costs and reasonable steps to increase income and
reduce costs where possible; and that you haven't arranged your situation to try and get this help.
If you want to re-apply for Temporary Additional Support you need to fill in this form and call us on 0800 559 009
to arrange a meeting. You should do this before your Temporary Additional Support is due to end.
Please bring this form to your meeting. You will also need to bring in identification, proof of your costs if they
have changed and proof of any steps you have taken to get other assistance towards costs, increase income
and reduce costs where possible.
Page 1 of 12
R21 SYS (April 06)
Current Address
1. Has your address changed?
No Go to Question 5 Yes Please give details below
Please give your house number, street, suburb, and town or city.
A house number could include: street number, fire, RAPID or
emergency service number
Flat/House no. Street name
Suburb Town/City
2. What is your mailing address (if different from above)? A mailing address could include: street address,
postal box (P O Box), rural delivery details or C/O address
3. How do we contact you?
Daytime phone Mobile phone Other phone/fax Email address
4. Do you live alone?
No Please give the details of the Yes
others you live with below
First Name Surname Relationship to you
Accommodation Costs Accommodation costs may be included in Temporary Additional Support
as an allowable cost
5. Have your accommodation costs changed?
No Yes Please give details below
Please bring proof of these costs
How often (weekly,
Company or person you pay Your cost fortnightly etc)
Rent $
Board $
First mortgage $
Other mortgage $
House insurance $
Mortgage insurance $
Ground lease $
Rates (including water rates) $
Cost of essential repairs $
and maintenance for the
last 12 months
Page 2 of 12
Partner Details A partner is a spouse (husband or wife), your civil union partner or someone of the
same or opposite sex with whom you have a relationship in the nature of marriage
6. Do you have a partner?
No Are you: Single Living apart / separated Divorced Widowed Civil Union dissolved
Yes Are you: Married In a relationship In a Civil Union
Children
7. You have been receiving assistance for the dependent children stated below. Have any of them left your care?
No Yes Please state the date they left your care below
Child's full name Date of birth Date left care
8. Are there any other children in your care?
Please give the names of any children that you or your partner financial support and are living with you as
a member of your family, including: stepchildren, children at boarding school, adopted children, children in
shared custody, grandchildren / mokopuna. If you are caring for a child who is not your own you may be
able to get Unsupported Child's Benefit or Orphan's Benefit. Please ask us about this
No Yes Please give details below
You may need to provide a Birth Certificate or passport for each child
Child's full name Relationship to you Date of birth
If you need more space please attach separate sheet showing these details
Page 3 of 12
Income Details
9. Are you and / or your partner receiving any income from any source?
Examples of income: wages or salary, Child Support, income from boarders, income from rents, Accident
Compensation, farm or business income (including drawings), self employment, interest from savings or
investments, dividends from shares, redundancy or termination type payments, Student Allowance,
Independent Circumstances Allowance or Student Loan living costs, family trust, overseas pension
No Yes Please give details below and provide proof of this income if we do not have it already.
Please provide gross (before tax) amount
How often (weekly,
Source (eg name of employer You Your partner fortnightly etc)
$ $
$ $
$ $
$ $
$ $
$ $
10. Do you and / or your partner receive any Family Assistance payments from Inland Revenue?
Family Assistance payments include: Best Start Tax Credit, In-Work Payment, Child Tax Credit, Family Tax
Credit, Parental Tax Credit
No Yes Please give details below and provide a Certificate of Entitlement from Inland Revenue.
You can get a Certificate of Entitlement by calling Inland Revenue on 0800 257 720.
Please have your IRD number available
How often (weekly,
Type of payment You Your partner fortnightly etc)
$ $
$ $
$ $
$ $
$ $
11. Do you and / or your partner expect to get future income in the next 52 weeks?
Examples of future income: year end payment of Family Assistance, confirmed employment, any lump sum
or future payments not included in questions 9 and 10
No Yes Please give details below
Please provide gross (before tax) amount
How often (weekly,
Source (eg name of employer) You Your partner fortnightly etc)
$ $
$ $
$ $
Page 4 of 12
Assets
12. Do you and / or your partner have any cash assets?
Examples of cash assets: money in a bank or savings organisation, money lent to other people or
organisations, money in Bonus Bonds, shares, debentures or stock
No Yes Please give details below and provide proof of these
assets if we do not have these details already
Type of asset You Your partner Jointly owned
$ $
$ $
$ $
$ $
$ $
$ $
13. Do you and / or your partner have any non-cash assets?
Examples of non-cash assets: caravan, boat or vehicle worth more than $2,000 that is not used as your
home; land or buildings other than your home. do not include the main vehicle you use
No Yes Please give details below and provide proof of these
assets if we do not have these details already
Total value of asset
Type of asset You Your partner Jointly owned Any money owing
$ $
$ $
$ $
$ $
$ $
Page 5 of 12
Allowable Costs Temporary Additional Support may be able to assist with some regular
essential costs. You should not arrange your situation to try and get this help.
Health or Disability Costs
Essential health or disability costs may be included in Temporary Additional Support if:
l you do not get Disability Allowance because of your income, or the health or disability condition will last
less than 6 months or
l these costs are more than your Disability Allowance pays for.
14. Do you and / or your partner or any dependent children have any health or disability costs?
Include children on Orphan's Benefit or Unsupported Child's Benefit.
No Go to Question 16 Yes Go to Question 15
15. Do you and / or your partner or any dependent children receive a Disability Allowance for health or
disability costs? Include children on Orphan's Benefit or Unsupported Child's Benefit.
No Talk to us about applying for a Yes Talk to us if your costs have changed
Disability Allowance
Credit Sales (Hire Purchases) and Regular Costs
16. You have been receiving assistance for the credit sales (hire purchases) and other allowable costs stated
below. Have these costs changed?
No Go to Question 18 Yes Go to Question 17
How often
Item Amount (weekly, fortnightly etc) End Date
17. Please give details below of any new credit sales (hire purchases) or regular costs, and details of any
changes to the costs in Question 16. Please bring proof of these details.
The item must be essential. Items that may be included: beds, dining suite, fridge/freezer, portable heaters,
lounge suite, stove, television, vehicle repayment, washing machine or laundrette costs, dryer (disability)
and childcare costs (disability)
How often
Item Amount (weekly, fortnightly etc) Start / Purchase date End date
$
$
$
$
$
$
$
$
Page 6 of 12
Employment Costs
18. Do you and / or your partner have any essential employment costs not listed or changed in Question 16?
Employment costs include: vehicle running costs or public transport to employment, childcare if the caregiver is working,
and a telephone if it is a condition for employment
No Yes Please give details below and provide proof of these costs
if we do not have these details already
Employment cost Amount How often (weekly, fortnightly etc)
$
$
$
Personal Safety and Special Family Circumstances
19. Do you and / or your partner need a telephone for safety or security reasons, or because of special family
circumstances?
Telephone costs for personal safety and security need to be verified by either the police; court order; women's refuge;
previous history held by Work and Income; Child, Youth and Family; or any other relevant organisation
No Yes Please provide details below. You may need to provide proof of your circumstances
and your telephone rental costs (excluding toll or call charges and cell phones) if we
do not have these details already
Details of Circumstances
Amount $ How often (weekly, fortnightly, etc)
Necessary and Reasonable Steps
As Temporary Additional Support is last resort financial assistance, you and your partner must take all necessary steps to get
other assistance towards costs and take reasonable steps to increase income or reduce costs where possible.
20. Please indicate what steps you and / or your partner have taken to get other assistance, reduce costs or increase
income.
Page 7 of 12
Page 8 of 12
Client's copy
Client's Information
Privacy & Social Security Act
The Social Security Act allows us to check the information that you have given us in this form.
This may happen when you apply for a benefit and at any time after that.
The Privacy Act requires us to inform you that:
l The information provided in this form is being collected under the authority of the Social Security Act 2018.
l The information will be held by Work and Income.
l The information is being collected for the functions and purposes of Work and Income, and in particular
- the granting of benefits and other financial assistance under the Social Security Act 2018,
- the provision of employment related services,
- statistical and research purposes,
- the provision of advice to Government.
l Work and Income may contact health providers to verify any health related information provided on this form.
l Work and Income may provide information about you to employers to find you employment. Where Work and Income refer
you to a job vacancy, Work and Income may also contact the employer to assess the outcome of any job interview that you
may have attended.
l The information you have provided may also be shared between childcare centres and Work and Income for the purpose of
administering your entitlement to childcare.
l Other information that you give us on your skills, aspirations etc, is not required to assess your entitlement to a benefit but
will be used to provide a better service to you.
l The information you have provided may be compared with information held by Inland Revenue, the Ministry of Justice, the
Department of Corrections, the New Zealand Customs Service, the Department of Internal Affairs, the Accident
Compensation Corporation, Housing New Zealand Corporation and the New Zealand Immigration Service. It may also be
compared with Social Security information (for example, pension or benefit information) held by other governments
(including Australia and the Netherlands).
l Under the Tax Administration Act 1994, if you have dependent children, the information you have provided may be shared
with Inland Revenue for the purpose of administering Family Assistance.
l 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.
l Under the Privacy Act you have the right to request access to all information held about yourself and to request corrections
to that information.
l It is not compulsory to provide us with information but if you do not provide us with all the information we request, your
application may be declined.
Warning
If you give us false or incomplete information, or don't tell us about changes that could affect your payments, your payment may
be cancelled. You'll have to pay back any money you are overpaid. You could also be prosecuted and fined or imprisoned.
Client's Obligations
I and my partner must take all necessary steps to get other assistance towards costs and take reasonable steps to increase
income and reduce costs where possible.
I must tell Work and Income immediately if either my partner or I:
l have a change in work situation (such as starting part-time, casual or full-time work, whether paid or unpaid)
l become self employed / start to run a business
l have changes to my/our income or financial circumstances
l intend to travel overseas
l start / finish part-time or full-time study
l have changes to personal details (such as name, address or bank account number)
l have changes to my/our living situation (such as marriage or separation, starting or ending a civil union, starting or ending a
de facto relationship with someone of the same or opposite sex, change in the number of children supported, change in
accommodation costs)
l are imprisoned / held in custody on remand
l are admitted to or discharged from hospital
l have been granted an overseas pension
l have any other change that may affect my/our benefit entitlement or rate.
Additional Information
Contact name Information required by
Day Month Year
Page 9 of 12
Page 10 of 12
Staff copy
Client's Obligations
Please read this statement and sign
I and my partner must take all necessary steps to get other assistance towards costs and take reasonable
steps to increase income and reduce costs where possible.
I must tell Work and Income immediately if either my partner or I:
l have a change in work situation (such as starting part-time, casual or full-time work, whether paid or unpaid)
l become self employed / start to run a business
l have changes to my / our income or financial circumstances
l intend to travel overseas
l start / finish part-time or full-time study
l have changes to personal details (such as name, address or bank account number)
l have changes to my/our living situation (such as marriage or separation, starting or ending a civil union,
starting or ending a de facto relationship with someone of the same or opposite sex, change in the number of
children supported, change in accommodation costs)
l are imprisoned / held in custody on remand
l are admitted to or discharged from hospital
l have been granted an overseas pension
l have any other change that may affect my / our benefit entitlement or rate.
My obligations have been explained to me and I understand my responsibilities.
I have completed all the questions in this Temporary Additional Support Application, or this application has
been completed for me, and the information I have given is true and complete. The conditions for receiving this
assistance have been explained to me and I understand these.
I am also aware of and understand the Privacy Act statement contained in this application form.
Name (print) Client's Signature
Day Month Year
Page 11 of 12
Office Use Only
Statement by Interviewing / Interpreting Officer
I have explained the conditions for receiving this assistance and explained what the client's and their partner's
obligations mean and the reason for them. The client and their partner have indicated that they understand and
accept responsibility to provide true and complete information and to advise immediately of any changes in
circumstances. All questions have been completed.
Name (print) Interviewing Officer Signature
Day Month Year
Additional Information
Decision
Letter Reference Processing Officer
Day Month Year
10% 100% Critical Data Service Quality Officer
Day Month Year
Service Centre Manager (if applicable)
Page 12 of 12
Work and Income is a services of the Ministry of Social Development - Te Manatu Whakahiato Ora. R21 SYS (April 06)
General information
workandincome.govt.nz
Visit our website any time for: You can sign up to MyMSD and:
• job vacancies • declare your wages
• tips on finding work • change your contact details
• information about the ways • update your address and accommodation
we can help you costs
• the things you need to do when • read your letters
you’re getting a benefit
• view your payment details
• your rights and responsibilities
• check your payment card
• how your wages will affect your
• view your debt and repayments
payments
• manage some of your appointments
If you don’t have access to our website, you can also call us. We are available 7am to 6pm Monday to
Friday, as well as 8am to 1pm on Saturdays. Call 0800 559 009 for more information or to make an
appointment. Please have your client number handy. It can be found on the front of this letter.
If you’re meeting with us you may bring a support person with you.
If you’re deaf, hearing-impaired or find it hard to communicate by phone, you can also contact us on:
Free-fax 0800 621 621 Telephone typewriter (TTY) 0800 111 113 Text 029 286 7170.
Changes in your Your rights if you
circumstances disagree with a
It’s important to tell us straight away about decision we’ve made
any changes that could affect your payments
so we pay you the right amount. If you don’t understand or agree with a
decision we’ve made, please talk with us.
When you should contact us:
If you disagree with any decision you have
• work situation changes a right to apply for a review. An application
• starting or ending a relationship for review needs to be made in writing within
three months of the decision. You can use the
• leaving New Zealand for any length of time review of decision or medical appeals board
• a child comes into or leaves your care application forms on our website or write to us.
• starting or stopping study If you can’t do this within three months,
please talk with us.
• getting money you haven’t declared
before from any source If you have a good reason for a delay,
your review may still be considered.
• getting other help that changes
your situation Visit:
• personal details change (eg address workandincome.govt.nz/rights
or bank account number) for more information.
• any name changes for you, your
partner or child
