Application for a War Funeral Grant (Regulation 45 of the War Pensions Regulations 1956)

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1 Application for a War Funeral Grant (Regulation 45 of the War Pensions Regulations 1956) Who completes and signs this form This form is completed and signed by the applicant; or Any person requested by the applicant can complete the form but the applicant must sign the application. Eligibility Regulation 45 of the War Pensions Regulations 1956 provides the Secretary for War Pensions with the discretion to pay a War Funeral Grant where: a veteran s death is accepted as attributable to service, or a veteran s death has not been found to be attributable to service but the veteran: - is survived by a spouse, civil union partner, de facto partner and/ or a dependant child who are found to be eligible for a Surviving Spouse Pension or Child Pension in respect of the veteran's death; and - was in receipt of an Invalid's Benefit, Veteran's Pension or New Zealand Superannuation at the time of his or her death. In the case of a veteran who was in receipt of New Zealand Superannuation, the veteran's income immediately before death must not have prevented him or her from receiving an Invalid's Benefit. Where there is a surviving spouse, civil union partner, de facto partner and/or a dependent child, the veteran must also have been; in receipt of a permanent War Disablement Pension of 70% or more at the time of his or her death; or assessed as qualifying for a permanent War Disablement Pension of 70% or more had he or she not died. The War Pensions Claims Panel will determine whether death is considered attributable to service. Payment of a War Funeral Grant will also depend on when the veteran served and the theatre of service. Why complete this form Assistance You should complete this form if you believe any of the above criteria will be met. If you have any questions about filling out this form, you should contact Veterans Affairs New Zealand (VANZ) on free phone (or if calling from overseas), or a person from an ex service organisation. This form can be downloaded from the VANZ website at July /11

2 Application for a War Funeral Grant (Regulation 45 of the War Pensions Regulations 1956) Parts of the form that need to be completed Documents required with this application Who can certify documents Please complete the appropriate Parts of the application form. Applicant to complete Parts 1-2 and 4-7. Part 3 only to be completed where the veteran was not in receipt of a War Disablement Pension Part 5 is to be completed by the veteran s Medical Practitioner where the late veteran was not receiving a War Disablement Pension or was not on 70% or more permanent War Disablement Pension. Please note any costs associated with the gathering of this information will need to be met by the applicant. Complete checklist on page 9 and ensure all supporting documentation is attached. In order for us to process your claim you need to provide us with: a copy of the veteran s death certificate (if not already provided); a copy of the itemised funeral account; if the funeral account has been paid in full, the receipt showing who paid the account; an original pre printed bank deposit slip or an original or certified copy of a bank statement showing bank account number and full name of the person who paid the funeral account. Original documents must be photocopied and certified as true copies by one of the following: Work and Income Justice of the Peace Solicitor Police Officer Registered Medical Professional Court Registrar Or other people authorised to take a statutory declaration. July /11

3 War Funeral Grant Please write in BLOCK LETTERS with a blue or black pen only. Part 1 Applicant s Details Title Mr Mrs Miss Ms Dr Rev Other Surname Given Name/s 4 Residential Address Country (if not New Zealand) Postal Code 5 Postal Address If different from above Country (if not New Zealand) Postal Code 6 Other Contact Details Home Phone Work Phone Mobile Number Fax number E mail 7 Relationship to veteran Part 2 Veteran s Details 8 War Pension / Work and Income Number (if known) 9 Title Mr Mrs Miss Ms Dr Rev Other Surname Given Name/s Date of Death Date of Birth 13 Relationship status at time of death Married De-facto Civil Union Single Separated Divorced 14 Full name of late veteran s partner (if applicable) July /11

4 War Funeral Grant Smoking What was the veteran s occupation/ s before enlistment? What was the veteran s occupation/ s after discharge? Was the veteran ever a smoker? i.e cigarettes, pipe, cigars Yes No Don t know 18 Pensions Please indicate which, if any, of the following pensions the veteran was in receipt of at the time of his or her death: War Disablement Pension Veteran s Pension Invalid s Benefit New Zealand Superannuation War Pension from another country Other Pension from another country If the veteran received a pension from another country, please state both the name of the pension and the name of the country. 19 Dependent Children Did the veteran have any dependent children? Yes No Children that were living with a veteran as a family member who was financially supported by the veteran, including: stepchildren; children at boarding school; adopted children; and grandchildren. If you answered yes, please complete this section. 1st child s full name Date of Birth Relationship to deceased veteran 2nd child s full name Date of Birth Relationship to deceased veteran 3rd child s full name Date of Birth Relationship to deceased veteran July /11

5 War Funeral Grant Part 3 Service Details Complete Questions 20 to 25 if the veteran was NOT in receipt of a War Disablement Pension at time of death 20 Branch of service veteran served in? i.e Army, Navy, Air Force 21 Service number 22 Service dates Enlisted Discharged 23 Trade/Corps/ Branch If more than one trade, state the period veteran worked in each. 24 Operational Deployments Please state all operational deployments, War or Emergencies the veteran served in as a member of the New Zealand Armed Forces. 25 Prisoner of War Was the veteran a Prisoner of War? Yes If you answered yes, please state where the veteran was captured and imprisoned and the dates held. No Captured Released July /11

6 War Funeral Grant Part 4 Funeral Details 26 Funeral Director 27 Funeral Director s Address 28 Funeral Director s Contact details Phone number E mail Fax number 29 Funeral Account Please provide a copy of the funeral account and receipt if paid. The receipt must show the name of person who paid the account. Has the funeral account been paid? If yes, who paid the account? Yes No 30 War Funeral Grant to be paid to Please provide verification of bank account name and number for person who paid the funeral account i.e certified copy of bank statement, pre printed deposit slip stamped by the bank. 31 Reference/Code For payment if account is Outstanding. Name of bank Branch Account Name Bank Branch Account number 32 Funeral Grant Has any assistance been received by another agency (example Work and Income, ACC, RSA, Prepaid Funeral, Finance Company or Insurance Agency)? Yes No If yes, please state who by. Amount of grant received $ 33 Executor details If you are not the Executor of the Estate please provide the executor s full name, address and contact details. Name of individual Name of business (if applicable) Address Country (if not New Zealand) Home Phone Mobile Number Work Phone Fax number Postal Code E mail July /11

7 War Funeral Grant Please write in BLOCK LETTERS with a blue or black pen only. Part 5 Medical Practitioner to complete Medical records are only required to support this application where the late veteran was not receiving a War Disablement Pension or was not on 70% or more permanent War Disablement Pension. Any costs associated with the gathering of this information will need to be met by the applicant. 34 Veterans Name 35 Veteran s NHI Number 36 Enrolment History Was the veteran enrolled with your practice? Yes No If yes, how long was the veteran enrolled with you? Years Months If no, please provide the name and contact details of the veteran s usual medical practitioner and practice (if known). Name of Practitioner Practice Name Please provide a brief summary of each medical condition the veteran suffered from prior to his/her death. 37 Medical Diagnosis: Date first diagnosed: How long did you treat this condition for? Was this condition current at the time of the veterans death? Yes No What would you assess the level of disablement/severity to have been? Did you refer the veteran to a specialist for an assessment of this condition? Yes No Do you have a copy of the specialist report? Yes No If yes please attach a copy of the report, if no please provide contact details of specialist 38 Medical Diagnosis: Date first diagnosed: How long did you treat this condition for? Was this condition current at the time of the veterans death? Yes No What would you assess the level of disablement/severity to have been? Did you refer the veteran to a specialist for an assessment of this condition? Yes No Do you have a copy of the specialist report? Yes No If yes please attach a copy of the report, if no please provide contact details of specialist PLEASE USE ADDITIONAL SHEETS IF NECESSARY July /11

8 War Funeral Grant 39 General comments on the veterans overall health 40 Medical Practitioner Identity HPI No. Medical Council Registration No. Name Practice Stamp (or address and telephone number) 41 Medical Practitioner s Signature July /11

9 War Funeral Grant Part 6 Income Assessment 42 Income Veterans total gross income for the 52 weeks prior to death. Did the veteran receive any income other than NZ Super, Veterans Pension or War Disablement Pension in the last 52 weeks? Yes No Income includes; Employment income, ACC, Work and Income benefit, Serious Illness/Terminal income from private insurer, Private superannuation, Disbursements from a Trust, Interest from savings and investments, Share dividends, Income from rent, Drawings from a business, Any other form of income If yes, please provided details below. Source of Income Total gross income over 52 weeks prior to death July /11

10 War Funeral Grant Part 7 Privacy Statement This application form needs to be signed. If someone has completed this form for you, you need to make sure that you agree with what he or she has written prior to signing the form. 43 Privacy Statement The information you give us is collected under the legislation administered by New Zealand Defence Force (NZDF). The information is collected for the following purposes: granting current and future pensions, allowances, and other assistance under the War Pensions Act 1954 and War Pensions Regulations providing advice to the Government. VANZ may contact other agencies to obtain information that is relevant to the processing of this application, including: service and medical documents from the NZDF or National Archives. details of any claim made to the Accident Compensation Corporation or similar organisation for any claimed medical condition. details of entitlements administered by the Ministry of Social Development / Work and Income. information on any medical condition the late veteran had from their medical practitioner, medical specialist, or other health professional. Under the Privacy Act 1993 you have the right to access all information we hold about you, and to request corrections to that information. You are not required to give us any information, but if you do not give us all the information we ask for, your application may be declined. 44 Part 8 Declaration Declaration We may provide a copy of this Privacy Statement and declaration to other agencies or persons when requesting further information. I declare that the information provided in this application form is, to the best of my knowledge, true and complete. I have read and understood the Privacy Statement set out above and I acknowledge that, as part of processing this application, VANZ will seek to verify the information I have provided. Applicant s Signature 45 Assistance Completing Application If you have had assistance in completing this form please print the name of the person who assisted you and the name of the organisation that they represent (if applicable). July /11

11 War Funeral Grant Claimants Checklist Have you: Completed numbers 1-33 and 42 of this form in BLUE or BLACK pen. Had the late veteran s medical practitioner complete numbers and sign the form at number 41 (if applicable). Enclosed copy of Veteran s death certificate. Enclosed copy of funeral account. Enclosed copy of funeral account receipt, showing the name of the person who paid the funeral account (if applicable). Enclosed an original or certified copy of bank statement showing the name and account number for the person who paid the funeral account. Read the Privacy Statement and signed and dated the declaration at number 44. Send your application to: War Funeral Grant Application Veterans' Affairs New Zealand P O Box 9448 Waikato Mail Centre HAMILTON 3240 War Funeral Grant Acknowledgement Receipt This is to acknowledge receipt of your application by Veterans Affairs New Zealand. You will be contacted shortly. Please write your name and postal address details below. Office Date Stamp July /11

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