This application will be processed under the terms of the Agreement between the New Zealand Government and the Government of Malta.

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1 Application for New Zealand Superannuation under a Social Security Agreement Malta This application will be processed under the terms of the Agreement between the New Zealand Government and the Government of Malta Use this form when applying from Malta. NEW ZEALAND CLIENT NUMBER MALTA SOCIAL SECURITY NUMBER (if known) New Zealand Superannuation Senior Services - International and Work and Income are services of the Ministry of Social Development. They administer New Zealand Superannuation under social security agreements. If your application is successful, Senior Services - International will be your main point of contact for the administration of your superannuation. Contact Details Senior Services - International Ministry of Social Development PO Box Wellington 6141 New Zealand Ph: Fax: Website Note: When calling from overseas replace the '+' with the international direct dial prefix for the country you're in. Please keep pages 1 to 4 of this application form for your reference. 1

2 What to provide two documents to prove who you are (one must be your passport, European Union National identity card, birth certificate or driver licence, the second can be any other similar document eg certificate of identity or marriage certificate) proof of any name change eg marriage or civil union certificate, official copy of name change by deed poll or statutory declaration bank book, deposit slip or bank statement showing your bank account number if you have a partner they will need to complete pages of this form. Obligations You must tell Senior Services - International immediately if you: intend to travel or move to another country, as it may affect your payments change your personal details (such as name, address or bank account number) change your living situation (marry, separate or commence living in a relationship in the nature of marriage, enter or leave a civil union relationship) have any other changes that may affect your pension entitlement or rate (such as death of a partner). Please note: If you would like to appoint an agent to act on your behalf when dealing with Senior Services - International, please contact us. Warning You need to understand that if you: have made a false statement, or have failed to answer all the questions in full, or do not tell Senior Services - International about changes in your life that might affect your entitlement or rate of payment, then your entitlement to a New Zealand Superannuation may be reviewed and/or cancelled and you may have to pay back the total amount of any overpayment that you have received, and Senior Services - International may impose a penalty (up to three times the value of the overpayment). 2

3 Privacy Statement The legislation administered by the Ministry of Social Development allows us to check the information that you give us in this form. This may happen when you apply for a benefit and at any time after that. The Privacy Act The New Zealand 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 Social Development. 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 Senior Services - International, Work and Income, Child Youth and Family and other services of the Ministry), and in particular for: granting benefits/pensions and other assistance under the Social Security Act 1964, the New Zealand Superannuation and Retirement Income Act 2001, the Social Welfare (Transitional Provisions) Act 1990, the War Pensions Act 1954 and the Reciprocal Agreement on Social Security between the New Zealand Government and the Government of Malta statistical and research purposes providing advice to Government. 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 Accident Compensation Corporation, Housing New Zealand Corporation, Ministry of Health and Immigration New Zealand. It may also be compared with social security information (for example, pension or benefit information) held by the Government of Malta. Under the Tax Administration Act 1994, if you have dependent children, the information you give us may be shared with 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 Ministry of Business, Innovation and Employment, Statistics New Zealand, the Ministry of Justice, the Accident Compensation Corporation, and the Ministry of Education disclose your personal information to your partner. 3

4 Under the Privacy Act 1993 you have the right to ask us to see all information we hold about you, and to ask us to correct that information. You are not required to give us information: but if you do not give us all the information we ask for your application for benefits may be declined. Please keep pages 1 to 4 of this application form for your reference. 4

5 Application for New Zealand Superannuation under a Social Security Agreement Malta NEW ZEALAND CLIENT NUMBER MALTA SOCIAL SECURITY NUMBER (if known) Your details 1. What is your full name? First names Surname or Family Name 2. Are you known by or have you ever used any other names? (such as a maiden name, birth name or alias) No (go to question 3) Yes (please tell us any other names you have used in the past, including your birth name) First names Surname or Family Name type (eg maiden name 3. What title do you wish to use? Mrs Miss Ms Mr No title Other 4. What is your date of birth? 5. Are you: Male Female Day month year 6. Where were you born? (Name the town or city and country) 5

6 7. Where do you live? Unit/house number and street Suburb Town or city Post code State Country 8. What is your mailing address? (if different from where you live) Unit/house number and street Suburb Town or city Post code State Country 9. What is your contact telephone number? (Please show country and area codes) If you do not have a phone, give a friend s or relative s number so we can contact you if necessary 10. Do you have a fax number? No Yes (please show country and area codes) 11. Do you have a mobile telephone number? No Yes (please show country and area codes) 12. Would you like us to contact you by ? No Yes (please show your address below and read and sign the authorisation and disclaimer on page 10) 6

7 New Zealand Benefits 13. Do you receive any type of benefit, pension or allowance from New Zealand? No (Go to question 14) Yes What type of benefit, pension or allowance? Go to question Have you ever received a benefit, pension or allowance from New Zealand? No Yes What type of benefit, pension or allowance? 15. What is your New Zealand client number? Residency (if known) 16. What countries have you lived in? Please list ALL countries including New Zealand Name of Country From dd/mm/yyyy To dd/mm/yyyy Purpose (eg usual residence, work, study) 7

8 Bank Details 17. What bank account do you want the New Zealand Superannuation to be paid into? (The account must be in your name and must be verified as correct by the bank or social security agency where you lodge your application.) Name of bank (eg ANZ, Citibank) Name of Branch Full address of bank Number and street Suburb Town or city The account is in the name of Country The account number IBAN Code Bank Branch Account Number Bank Identification code (you may need to ask your bank for this) Verified by (Must be signed and stamped by the bank or social security agency staff. A copy of a bank statement, deposit slip or other bank generated document showing the account name and number is also acceptable.) 8

9 War / Veteran s Pension entitlement 18. Have you served with the New Zealand Armed Forces? No Yes You may be entitled to Veteran s Pension. Please contact Senior Services International for more information. Partner Details 19. Do you have a partner? A partner is your spouse (husband or wife), your civil union partner or a person of the same or opposite sex with whom you have a de facto relationship. No Are you? Single Living apart/separated Divorced Widowed Civil Union dissolved Yes Are you? Married In a de facto relationship Civil Union 20. What is your partner s name? First names Surname or Family Name 21. What is their date of birth? Day month year Please ask your partner to fill in the Partner Details section on pages 12 and 13 9

10 Authorisation and Disclaimer (please only complete this disclaimer if you would like us to contact you via ): 1. I authorise Senior Services - International, a service of the Ministry of Social Development, to communicate with me at the address I have provided. 2. I accept responsibility for access to my address, including any information that Senior Services - International may send to this address. I understand that allowing other people to access my account may result in their access to my personal information and correspondence sent to this address by Senior Services - International. 3. I accept that Senior Services - International will not be liable for any unauthorised access to any personal information that Senior Services - International sends to this address. 4. I accept that if Senior Services - International attaches copies of other correspondence to an , the copy that Senior Services - International holds will be treated as the correct and original correspondence. 5. I accept that I am responsible for any information sent from my account to Senior Services - International and I understand that Senior Services - International can accept any information coming from my account as having been sent by me. 6. I understand that, if I have supplied incorrect contact information, or if the delivery delay or failure is outside the control of Senior Services - International, Senior Services - International will not be responsible for the non-delivery of correspondence to this address. 7. If at any time I wish to discontinue correspondence with Senior Services - International via this address, I will notify Senior Services - International in writing. If I wish to change my address, I will submit a new authorisation of address form to Senior Services - International. Please sign here Day month year 10

11 Client Obligations Please read this statement carefully and sign. I must tell Senior Services - International immediately if I: intend to travel or move to another country change my personal details (such as name, address or bank account number) change my living situation (marry, separate or commence living in a relationship in the nature of marriage, enter or leave a civil union relationship) have any other changes that may affect my benefit/pension entitlement or rate. I will advise the person who will take care of my affairs in the event of my death that I am receiving a New Zealand benefit or pension, and request that person to inform Senior Services - International immediately of my death. I understand that I am responsible for completing and returning life certificates either six-monthly or annually to Senior Services - International. If I do not return these certificates within the timeframe provided I understand that my New Zealand benefit or pension may be suspended until I do. The information I have given in this application is true and I have not left anything out. I am aware of, and understand, the Privacy Act and Social Security Act statement contained in this application form. I understand Senior Services - International will only release such information as necessary to an overseas social security agency where required under New Zealand social security legislation. Please sign here... Please print your name here... Date..... Date Stamp of authorised social security agency Office Use Only 11

12 Partner Details A partner is your spouse (husband or wife), your civil union partner or a person of the same or opposite sex with whom you have a de facto relationship. 1. What is your full name? First names Surname or Family Name 2. Are you known by or have you ever used any other names? (such as a maiden name, birth name or alias) No (go to question 3) Yes (please tell us any other names you have used in the past, including your birth name) First names Surname or Family Name type (eg maiden name 3. What title do you wish to use? Mrs Miss Ms Mr No title Other 4. What is your date of birth? 5. Are you: Male Female Day month year 6. Where were you born? (Name the town or city and country) New Zealand Benefits 7. Do you receive any type of benefit, pension or allowance from New Zealand? No Yes What type of benefit, pension or allowance? Go to question 9 12

13 8. Have you ever received a benefit, pension or allowance from New Zealand? No Yes What type of benefit, pension or allowance? 9. What is your New Zealand client number? (if known) Residency 10. What countries have you lived in? Please list ALL countries including New Zealand Name of Country From dd/mm/yyyy To dd/mm/yyyy Purpose (eg usual residence, work, study) 13

14 Warning You need to understand that if you: have made a false statement or have failed to answer all the questions in full or do not tell Senior Services - International about changes in your life that might affect your entitlement or rate of payment, then your entitlement to a New Zealand Superannuation may be reviewed and/or cancelled and you may have to pay back the total amount of any overpayment that you have received, and Senior Services - International may impose a penalty (up to three times the value of the overpayment). Privacy Statement The legislation administered by the Ministry of Social Development allows us to check the information that you give us in this form. This may happen when you apply for a benefit and at any time after that. The Privacy Act The New Zealand 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 Social Development. 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 Senior Services - International, Work and Income, Child Youth and Family and other services of the Ministry), and in particular for: granting benefits/pensions and other assistance under the Social Security Act 1964; the New Zealand Superannuation and Retirement Income Act 2001; the Social Welfare (Transitional Provisions) Act 1990; the War Pensions Act 1954 and the Reciprocal Agreement on Social Security between the New Zealand Government and the Government of Malta. statistical and research purposes providing advice to Government. 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 Accident Compensation Corporation, Housing New Zealand Corporation, Ministry of Health and Immigration New Zealand. It may also be compared with social security information (for example, pension or benefit information) held by the Government of Malta. 14

15 Under the Tax Administration Act 1994, if you have dependent children, the information you give us may be shared with 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 Ministry of Business, Innovation and Employment, 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 correct that information. You are not required to give us information: but if you do not give us all the information we ask for your application for benefits may be declined. Partner Statement Please read this statement carefully and sign The information I have given in this application is true and I have not left anything out. I am aware of, and understand, the Privacy Act and Social Security Act statement contained in this application form. I understand Senior Services - International will only release such information as necessary to an overseas social security agency where required under New Zealand social security legislation. Please sign here... Please print your name here... Date..... Date Stamp of authorised social security agency Office Use Only 15

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