24 January 2025
Client number:
Mr Wayne Hoare 4 0 2 3 8 6 6 6 5
8A Peter Hall Drive
Kelvin Grove
Palmerston North 4414
Kia ora Wayne
IT'S TIME TO REAPPLY FOR YOUR TEMPORARY ADDITIONAL SUPPORT
If you still need help with your costs, you'll need to reapply before 21 February 2025.
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 $250 . 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 21 February 2025 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
Justin Wilson
Manager Client Service Delivery
BP1 v7.0
To contact us visit [Link]/contact
Temporary Additional
Support
Re-application
To: Return the completed form to:
Mr Wayne Hoare Palmerston North
8a Peter Hall Drive Service Centre
Kelvin Grove
Palmerston North 4414
Full name Your first name Your surname or family name
Client number 4 0 2 3 8 6 6 6 5
Day Month Year
Your Temporary Additional Support will end on:
26 02 2025
You can re-apply for Temporary Additional Support if you and your partner still need help with your costs.
There are three ways you can re-apply
• The easiest and quickest way is to log into MyMSD and select ‘Reapply for Temporary Additional Support’.
• Call us on 0800 559 009 or if you’re over 65, call 0800 552 002 and say “Temporary Additional Support”.
• Complete this form and return it to us.
If you don’t re-apply before your Temporary Additional Support stops, we can only start again from the date
you re-apply.
Thank you
R21 (SYS) – JUL 2023 Page 1
Tell us about yourself
Tell us how 1 Has your address changed?
we can No Yes Please provide details below
contact you
Flat/House number Street name
HOW TO ANSWER Q1:
If you live in a rural
area, flat/house number Suburb Town/City
could include your RAPID
number, fire number,
emergency services
number. 2 Is your mailing address different from where you live?
HOW TO ANSWER Q2: No Yes Tell us your mailing address
Mailing address can
include a PO Box, rural Flat/House number Street name
delivery details, or C/O
address.
Suburb Town/City
HOW TO ANSWER Q3: 3 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 ( )
Tell us 4 Do you live alone?
about who No Please give details of the others you live with below Yes
you live with
First and middle names Surname or family name Relationship to you
Page 2 R21 (SYS) – JUL 2023
Tell us 5 Have any children left your care since your last application for Temporary
about your Additional Support?
dependent No Go to question 6 Yes Please provide details below
children Child 1
Full name
Date of birth Date left care
Day Month Year Day Month Year
Child 2
Full name
Date of birth Date left care
Day Month Year Day Month Year
Child 3
Full name
Date of birth Date left care
Day Month Year Day Month Year
Child 4
Full name
Date of birth Date left care
Day Month Year Day Month Year
Child 5
Full name
Date of birth Date left care
Day Month Year Day Month Year
Child 6
Full name
Date of birth Date left care
Day Month Year Day Month Year
Tell us about 6 Do you have a partner?
your partner By ‘partner’ we mean someone you’re in a relationship with. If you’re not sure, go to
[Link] and search on Are you in a relationship.
No Go to question 9 Yes
7 What is your partner’s full name?
8 What is your partner’s date of birth?
Day Month Year
R21 (SYS) – JUL 2023 Page 3
Tell us about your income and assets
Tell us 9 Do you or your partner get income from any of the following sources?
about Wages or salary No Yes
income Termination pay No Yes
in the last
52 weeks? Redundancy pay No Yes
ATTACHMENT FOR Q9: Accident compensation (eg ACC) No Yes
Bring a copy of your
business accounts. Income insurance (replacement/protection) No Yes Jointly with partner
INFORMATION FOR Q9 : Farm or business income No Yes Jointly with partner
In this application form,
‘partner’ means the Payments from self employment or contract work No Yes Jointly with partner
person you’re married
to or in a civil union or Interest from savings, investments, or bonds No Yes Jointly with partner
relationship with, not a
business partner. Dividends from shares, unit trusts, or
managed funds No Yes Jointly with partner
Income from rents No Yes Jointly with partner
Payments from three or more boarders or
flatmates No Yes Jointly with partner
Child support payments (private arrangement or
through Inland Revenue) No Yes
Other income for a child No Yes
Maintenance payments No Yes
Payments from a former partner No Yes
Student Allowance, scholarship, or Student Loan
living cost payments No Yes
Overseas pension, benefit or allowance payments No Yes
Other superannuation or retirement scheme
income (government or private) No Yes
Income from an estate, if you’ve inherited money No Yes Jointly with partner
Income from trusts No Yes Jointly with partner
Other No Yes Jointly with partner
ATTACHMENT FOR Q10 : Did you answer ‘yes’ or ‘jointly with partner’ to any of the sources of income
10
You’ll need to show us listed in question 9?
proof of income.
No Yes Tell us the total before-tax amounts you get
HOW TO ANSWER Q10:
The types of income Where does the income
you need to include come from? You Your partner Jointly with partner
here are listed in
question 9. $ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Page 4 R21 (SYS) – JUL 2023
11 Do you expect to get income or other payments in the next 52 weeks?
No Yes Please write the details below. Tell us the before-tax amounts
Where will the How often do
payment come Jointly with you expect the
from? You Your partner partner payment?
$ $ $
$ $ $
Tell us about 12 Do you or your partner get any Working for Families tax credit payments from
any Working Inland Revenue?
for Families No tax credit Family tax credit Minimum family tax credit
tax credits
Parental tax credit In-work tax credit Best Start tax credit
you get
Please write the details of any credit below.
How often
(weekly,
Type of tax credit You Your partner fortnightly, etc)
$ $
$ $
Tell us 13 Do you or your partner have any of the following cash assets?
about Money in bank or other savings No Yes
your assets
Bonds, shares, debentures or stocks No Yes
ATTACHMENT FOR Q13:
You may be asked to Money lent to other people or organisations No Yes
provide proof of your
assets and their value. Other cash assets No Yes
14 If you answered ‘yes’ to any of the assets listed above, please write the
details below.
Type of asset You Your partner Jointly owned
$ $ $
$ $ $
HOW TO ANSWER Q15: Do you or your partner have any of the following non-cash assets?
15
Examples of property
you don’t live in include, Property you don’t live in No Yes
land, holiday homes,
bach/crib, investment
Boat, caravan or motorhome No Yes
properties.
Other No Yes
ATTACHMENT FOR Q16: If you answered ‘yes’ to any of the non-cash assets listed above, please write
16
You may be asked to the details below.
provide proof of these How much do you
details. Type of asset How much is it worth? owe on it?
$ $
$ $
R21 (SYS) – JUL 2023 Page 5
Are you 17 Are you or your partner involved in a trust, or have you ever been involved in
involved a trust?
in a trust? ‘Involved’ means one or more of the following:
• you’ve set up a trust, usually by making a gift of assets or property
ATTACHMENT FOR Q85:
• you’ve transferred assets to a trust
You’ll need to show us
trust documents, such • you make decisions about managing a trust
as the trust deed, deed • you benefit from a trust, for example, by receiving income such as trust distributions.
of debt, gift statements,
accounts.
No Yes Please write the name of the trust
Name of trust
Tell us about your costs
Tell us what 18 Are you or your partner working?
essential No Go to question 20 Yes
work-related
costs you Do you or your partner have any essential costs that you have to pay
19
need to to keep working?
pay to keep
No Yes Please write the details below
working How often
(weekly,
INFORMATION FOR Q19:
Type of cost How much? fortnightly, etc)
These are the only
Running costs for a vehicle you use to get to and from work $
work-related
essential costs that Repayment costs for a vehicle you use to get to and from work $
we may be able to
help you with. Public transport to and from work $
Telephone, if it is a condition of your work $
ATTACHMENT FOR Q19:
You’ll need to show proof Childcare $
of these costs.
Accom- 20 Have your accommodation costs changed since you last told us?
modation costs No Yes Please give details below
How often (weekly,
Type of cost Company or person you pay Your cost fortnightly, etc)
Rent $
Board $
First mortgage $
Other mortgage $
House insurance $
Mortgage insuranace $
Rates $
Ground lease $
Water rates $
Body corporate fees $
Page 6 R21 (SYS) – JUL 2023
ATTACHMENT FOR Q21: Did you have to pay for repairs and maintenance to your home in the last
21
Bring receipts for any 12 months?
repair and maintenance
costs. No Yes Please write the total amount $
22 Have you received a rates rebate in the last 52 weeks?
No Yes Amount $ Rating year 1 July 20
to 30 June 20
Tell us 23 You’ve been getting help to cover the following costs. Have any of these costs
about other changed since your last application for Temporary Additional Support?
essential costs No Yes Please give details below
How often
INFORMATION FOR Q23:
(weekly,
Essential health or
Type of cost Amount fortnightly, etc) End date Changed
disability costs may be
included if: $ / /
• you don’t get $ / /
Disability Allowance
$ / /
because of your
income, or the $ / /
health or disability
condition will last $ / /
less than 6 months, $ / /
or
$ / /
• these costs are
more than your $ / /
Disability Allowance
pays for, or $ / /
• you’re a certain $ / /
refugee or residence
permit applicant. $ / /
$ / /
$ / /
$ / /
$ / /
INFORMATION FOR Q24: Do you or your partner have any new credit sales (hire purchases) or regular
24
Essential regular costs essential costs since your last application for Temporary Additional Support.
can include:
• hire purchase No Yes Please give details below
• vehicle repayments How often
• costs relating to (weekly, Start or
a health condition Item Amount fortnightly, etc) purchase date End date
or disability $ / / / /
• lease or hire of an
$ / / / /
essential household
item such as fridge, $ / / / /
washing machine,
stove. $ / / / /
$ / / / /
ATTACHMENT FOR Q24:
You’ll need to show
proof of these costs. If you don’t get the Disability Allowance and your costs are health-related, please tell us.
R21 (SYS) – JUL 2023 Page 7
Child If you pay child support and the monthly amount you have to pay is a ‘formula assessment’
support costs set by Inland Revenue, the child support can be included when we work out your
Temporary Additional Support. You don't have to provide this information but, if you
don't, you may not receive the full amount of Temporary Additional Support you're
eligible for. We can't include other types of child support.
INFORMATION FOR Q25: 25 Do you or your partner have child support costs?
You can find the date
Inland Revenue told No, I/we don't have child support costs, or don't want to include them. Go to question 30
you about a change to
your child support costs No, my/our child support costs have ended. Date you were told about the change
in MyIR or your ‘child
support to pay’ letter. Day Month Year
Date your child support costs ended
Day Month Year
Go to question 30
Yes, I/we have child support costs.
26 Is the amount you or your partner have to pay a formula assessment set by
Inland Revenue?
No Go to question 30 Yes
INFORMATION FOR Q27: 27 Please tell us the amount you or your partner have to pay.
You can find the Amount you have to Date you have to pay
amount you have to pay Who has to pay? pay each month this amount from
and the date you have
to pay it from in MyIR or Me $ / /
your ‘child support to pay’ My partner $ / /
letter.
28 Has the amount you or your partner have to pay changed since your last
application for Temporary Additional Support?
No
Yes, mine has changed Date you were told about the change
Day Month Year
Yes, my partner’s has changed Date you were told about the change
Day Month Year
Page 8 R21 (SYS) – JUL 2023
INFORMATION FOR Q29:
29 Please tell us how you’d like to provide proof of the child support you have
Details about how and
to pay.
when we share your
personal information can
be found at We’ll need proof of how much you have to pay. There are two ways to do this:
[Link]. • Inland Revenue can share the information with us.
nz/privacy If you agree, Inland Revenue can tell us about your monthly child support costs. They’ll share
your name, date of birth, IRD number as well as your current and expected child support costs.
We'll use this information to process the application for Temporary Additional Support.
You will still need to let us know if your child support costs change while you're getting
Temporary Additional Support. We'll work with you to make sure you're getting paid the right
amount and resolve any under or over payments.
They'll also tell us if they're managing other types of child support for you, even if it can't be
included in your application. We'll only use this information to help answer questions you
might have.
We'll ask for your consent each time you re-apply for Temporary Additional Support.
• You can provide your ‘child support to pay’ letter from Inland Revenue.
You will still need to let us know if the amount of child support you have to pay changes while
you're getting Temporary Additional Support.
I agree that Inland Revenue can share my child support costs if requested by the Ministry of
Social Development.
My partner agrees that Inland Revenue can share their child support costs if requested by the
Ministry of Social Development.
I do not agree to my information being shared, and will provide the ‘child support to pay’ letter
from Inland Revenue.
Personal 30 Do you need a telephone for safety or security reasons, or because of special
safety and family circumstances?
special family No Yes Please list the details below
circumstances
HOW TO ANSWER Q30:
Do not include toll or
mobile phone costs.
ATTACHMENT FOR Q30:
Unless we already
have this information,
please bring:
• proof of the need, such
as a Court Order, or
verification from Police,
Women’s Refuge, or a How much do you pay? $
similar organisation
• proof of phone How often? (weekly, fortnightly, monthly)
payments.
Tell us 31 What steps have you and your partner taken to get other help, reduce costs,
what you or increase income?
have done to
try to pay your
essential costs
R21 (SYS) – JUL 2023 Page 9
Obligations and signature Office copy
Let us know when things change
You need to let us know about changes that might affect the amount you’re paid, like:
• starting, stopping or changing jobs
• starting or finishing part-time or full-time study
• changes to your pay or other income, including getting an overseas pension
• starting to run a business (for yourself or someone else).
Changes to information about you or your family, like:
• name, address, contact details or bank account number
• starting or ending a relationship, marriage, or civil union
• a partner passes away
• the number of children in your care.
Change to where you live or how much it costs, like a rise or drop in your rent, board, mortgage or rates.
We also need to know if you:
• are travelling overseas
• go into or come out of hospital
• are being held in custody or on remand.
Your rights
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 [Link]/reviews
Privacy
Our online Privacy Notice tells you how we collect, use, share and keep your personal information safe. It also
has information about how you can access your personal information that we hold, and your right to ask for it to
be corrected if you think it is incorrect. To see our Privacy Notice go to [Link]/privacy
Signature
• I’ve answered all the questions that apply to me and my situation
• I understand the changes I need to let you know about
• The information I’ve given you is true and complete
• I understand what you do with my personal information and how you protect my privacy
• If I have given consent on page 9, the Ministry of Social Development and Inland Revenue can share
information about the child support I have to pay.
Applicant’s name (print) Applicant’s signature Date
Day Month Year
Partner’s name (print) Partner’s signature Date
Day Month Year
Page 10 R21 (SYS) – JUL 2023
