1 S02 DEC 2011

Who can get

this subsidy
If you need help flling in this form,
please ask at your nearest Work and
Income Service Centre.
Mehemea e hiahia me awhina a koe
ki te whakaki i tenei panui, haere
patai ki te poari o te Work and
Income tata tonu ki a koe.
Afai e te manaomia se fesoasoani
i le faatumuina o soo se pepa
talosaga e uiga i penefti,
faamolemole faafesootai le ofsa o
le Work and Income.
What to bring
Please ask Work and Income staff
for help if:
you do not have any of the
documents we have asked for
you think there could be a delay
in providing this information
you would like to know about
extra help.
3
If you are in work or study, or if there are special circumstances that mean you need access to
childcare, you may get:
a Childcare Subsidy for children under 5 years, or 6 years old if they receive a Child
Disability Allowance, up to 50 hours a week
an OSCAR Subsidy for before school and after school care up to 20 hours per week during
term time, and up to 50 hours during school holidays, for children aged 513 years, or 1418
years if they receive the Child Disability Allowance.
If you are not in work or study you may get a Childcare Subsidy for up to nine hours a week.
You can use this form for both subsidies and you can use it to apply for a subsidy for more
than one child. Your subsidy will start from the later of the:
date of application
date your child started attending the childcare facility.
If you have a 3 or 4 year old child, they may be able to receive up to 20 hours of free early
childhood education (20 Hours ECE). This will depend on the type of childcare service your child
attends and whether the centre offers free hours. For more information speak to your childcare
service.
To apply for the Childcare and OSCAR Subsidy, you will need to complete this application
form and provide the following for both you and your partner (if you have one):
For New Zealand born clients, one form of government-issued documentation stating your
full legal name and date of birth (eg your birth certifcate, passport, driver licence, frearms
licence, deed poll, etc)
For people born overseas, proof of your lawful residence in New Zealand (eg New Zealand
passport, other country passport with residence class visa or residence permit, citizenship
certifcate, etc)
Two more documents supporting your identity. These could include your marriage
certifcate, bank statement, phone or power account, driver licence, etc)
Note: One of the documents requested above must be at least 2 years old.
Full birth certifcates for your children if your children werent born in New Zealand, we
will need to see proof of their New Zealand citizenship or permanent residency.
Proof of your work, course, study and number of hours.
Proof of your income before tax payslips, business accounts or Child Support received.
Proof of your residency status (eg visa or certifcate of citizenship) if you were not born in
New Zealand.
If you need help with this form call us on
%
0800 559 009.
Childcare and OSCAR Subsidy Application
When to apply Apply now before your child starts the programme.
In order to receive your subsidy from the day your child starts the programme, you need to
submit your application to us before your childs frst day. This is especially important for school
holidays.
You can also apply online at www.workandincome.govt.nz
S02 DEC 2011 2 S02 DEC 2011
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 beneft and at any time after
that.
Important
Obligations
Work situation changes include starting
part-time, casual or full-time work,
whether paid or unpaid.
Changes in your living situation include:
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.
Additional information
Information required by
Day Month Year
Contact name
Your client number is:
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 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 Work and Income, Child, Youth and Family and other service lines
of the Ministry), and in particular for:
granting benefts and other assistance under the Social Security Act 1964
providing employment related services
statistical and research purposes
providing advice to Government
care and protection needs of children
providing support and services for you and your family
providing education related services.
Work and Income may contact health providers to verify any health related information you give
us.
Work and Income may give employers information about you to fnd you employment. Where
Work and Income refer you to a job vacancy, we may also contact the employer to discuss the
result of any job interview that you attend.
Work and Income may share information you have given us with childcare centres to administer
your entitlement to childcare assistance.
Other information that you give us on your skills, aspirations, family circumstances etc, and that
is not required to assess your entitlement to a beneft may be used to provide a better service to
you by the Ministry of Social Development.
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 beneft 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 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 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 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 benefts may be declined.
I must tell Work and Income immediately if I:
have a change in work situation
become self employed / start to run a business
have changes to my/our income or fnancial circumstances
intend to travel overseas
start / fnish part-time or full-time study
have changes to personal details (such as name, address or bank account details)
have changes to my/our living situation
am imprisoned / held in custody on remand
am admitted to or discharged from hospital
have been granted an overseas pension
have any other changes that may affect my/our beneft entitlement or rate.
I understand that:
if I have made a false statement or
if I have failed to answer all the questions in full or
if I do not tell Work and Income about changes in my life that might affect my entitlement or rate
then
my beneft may be reviewed and cancelled and
I may have to pay back the total amount of any overpayment that I have received and
Work and Income may impose a penalty (up to three times the value of the overpayment) or
I may be prosecuted and fned or imprisoned.
S02 DEC 2011 3 S02 DEC 2011
Name
Birth date
Address
Q5 note: Please give your house
number, street, suburb, and town
or city.
A house number could include:
street number
fre
RAPID
emergency services.
Q6 note: A mailing address could
include:
street address
postal box (PO Box)
rural delivery details
C/O address.
Q4 note: Please tick one box to show
the title you want to be known by.
Q2 note: Give any other names that
you use now or have used in the
past (including your maiden name).
Before you start
Childcare and OSCAR Subsidy Application Part A
Please check that you have all relevant What to bring items on the front of this form.
Please complete all questions if not applicable write N/A.
1. What is your name?
First name(s)
Surname or family name
2. Are you known by or have you used any other names?
No Yes u Please give details below:
1.
2.
3. Are you: Male Female
4. What do you want to be called?
Mrs Miss Ms Mr No title Other
5. Where do you live?
Flat/house no. Street name
Suburb City
6. What is your mailing address (if different from above)?
If you live at a rural address please include your rural delivery details here:
7. How can we contact you?
Work phone Home phone Mobile phone
Email Fax
8. What is your date of birth?
Day Month Year
Tax number
9. What is your Inland Revenue tax number?
CLIENT NUMBER
S02 DEC 2011 4 S02 DEC 2011
10. Indicate which describes your residency situation:
New Zealand citizen (by birth) u Go to Question 14
Date of citizenship
New Zealand citizen (other) u Go to Question 12
Day Month Year
Date permanent residence granted
Permanent resident u Go to Question 12
Day Month Year
Other u Go to Question 11
11. What is your residency status?
12. When did you arrive in New Zealand?
Day Month Year
13. Where were you born?
14. Do you usually live in New Zealand? No Yes
15. Have you lived in any countries outside New Zealand? No Yes
Work details 17. Are you currently working?
No u Go to Question 21
Yes u Please provide your employers details below:
Employers name
Business site address
Work phone Fax
18. How many hours a week, including lunch hours, do you spend at work?
19. How many hours a week do you spend travelling from the centre to work and returning?
20. What is your gross weekly wage? $
Residency
Q10 note: Tick one box.
Ethnic group
Q16 note: You dont have to answer
this question if you dont want to.
This information is for statistics and
will be used for research and future
development work.
Q14 note: This means that you
consider New Zealand your home,
you are a legal resident, usually live
here and intend to stay permanently.
16. To what ethnic group do you believe you belong?
New Zealand Maori u Which tribe(s)/iwi?
New Zealand European Niuean Samoan Indian
Other European Tokelauan Tongan Chinese
Cook Island Maori Other u Please specify below:
S02 DEC 2011 5 S02 DEC 2011
Offcial Training Providers stamp
21. Are you doing activities arranged for you by Work and Income?
No u Go to Question 25 Yes
22. What type of activities are you doing?
23. How many hours a week do you spend at that activity?
24. How many hours a week do you spend travelling from
the centre to your activity and returning?
Activity details
Education 25. Are you on a work-related course or studying?
Yes No u Go to Question 34
26. Which organisation provides the course?
27. What is the name of your course?
28. Is the course NZQA accredited?
No Yes
29. When does the course start?
Day Month Year
30. When does the course fnish?
Day Month Year
31. How many hours a week do you spend at your course?
32. How many hours a week do you spend on other study?
33. How many hours a week do you spend travelling from
the centre to your course and returning?
Trainers statement
This information is required under
section 12 of the Social Security
Act 1964.
I confrm that the above course details are true and complete.
Trainers name
Organisation
Organisation address
Work phone Fax
Trainers signature Date
Day Month Year
S02 DEC 2011 6 S02 DEC 2011
34. Do you have any dependent children in your care?
No u Go to Question 39 Yes u Please provide details below:
Childs full name Date of birth
1. / /
Relationship to you
Childs full name Date of birth
2. / /
Relationship to you
Childs full name Date of birth
3. / /
Relationship to you
35. Which children do you wish to receive Childcare Subsidy for?
CHILD 1:
Childs full name Date of birth
Day Month Year
Does this child receive 20 Hours ECE from any Childcare Service?
No u Go to next child or Question 36
Yes u How many hours are received per week, in total?
What date did the 20 Hours ECE start?
Day Month Year
Which centre does the child recieved 20 Hours ECE from?
CHILD 2:
Childs full name Date of birth
Day Month Year
Does this child receive 20 Hours ECE from any Childcare Service?
No u Go to next child or Question 36
Yes u How many hours are received per week, in total?
What date did the 20 Hours ECE start?
Day Month Year
Which centre does the child recieved 20 Hours ECE from?
CHILD 3:
Childs full name Date of birth
Day Month Year
Does this child receive 20 Hours ECE from any Childcare Service?
No u Go to Question 36
Yes u How many hours are received per week, in total?
What date did the 20 Hours ECE start?
Day Month Year
Which centre does the child recieved 20 Hours ECE from?
About your children
Q34 note: Children that you support
are any children that you fnancially
support and are living with you as a
member of your family, including:
stepchildren
children at boarding school
adopted children
grandchildren
mokopuna.
If you are caring for a child who is
not your own you may be able to get
other forms of assistance. Please
ask us about this.
Q35 note: The Childcare Subsidy is
for children aged under 5 years (or
under 6 years if they get the Child
Disability Allowance).
S02 DEC 2011 7 S02 DEC 2011
Income details
Q38 note: Examples of income
include:
wages or salary
accident compensation
farm or business income
self employment
interest from savings or
investments
dividends from shares
pensions
redundancy or termination type
payments
Child Support
overseas pensions
board or rent
Student Allowance or
Scholarship
any other income, eg family
trusts.
Give gross (before tax) amount.
38. Do you or your partner (if you have one) receive a weekly income?
No Yes u Please provide details below:
Your income Your partners income
Income source gross $ a week gross $ a week
(list jobs and other sources of income) BEFORE TAX BEFORE TAX
$ $
$ $
$ $
$ $
$ $
$ $
Totals $ $
Total combined income $
If you are self-employed, please provide your full set of business accounts for the last 12
months. If you income changed over the year, please provide your income details for the
last 26 weeks.
39. Have you or your partner received Childcare or OSCAR Subsidy at any time from
28 September 2009 up to and including 26 September 2010?
No Yes
Previous childcare
assistance
Q39 note: We are asking you this to
ensure that we will be paying you the
correct rate.
40. Do you have a partner?
No u Are you: Single Living apart/ separated Divorced
Widowed Civil union dissolved
u Go to Obligations on page 11.
Yes u Are you: Married In a civil union In a relationship
Partner
Q40 note: 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.
36. Do you want to apply for the OSCAR Subsidy for before and after school care and/or
school holiday programmes?
No Yes u Please provide details of which children you need the subsidy for below:
Childs full name Name of the centre they go to
1.
2.
3.
37. Do you require early childhood education care for your child(ren) for a reason other than
you or your partner working, studying, or doing activities arrranged by Work and Income?
No Yes u Please provide details below:
Q36 note: The OSCAR Subsidy is
for school children aged 513 years
(or 1418 years if they get the Child
Disability Allowance).
If your child is attending more
than one OSCAR School Holiday
Programme, you will need to
complete the OSCAR Subsidy-
Additional School Holiday
programme form.
Q37 note: Other reasons include
that you or your partner:
are temporarily unable to
continue employment because
of illness or injury
are attending an approved
rehabilitation programme
are a seriously disabled or ill
caregiver
have another child in hospital
other reason.
S02 DEC 2011 8 S02 DEC 2011
Partners Details
Please check that you have all relevant What to bring items on the front of this form.
Please complete all questions if not applicable write N/A.
Name
Birth date
Address
Q5 note: Please give their house
number, street, suburb, and town
or city.
A house number could include:
street number
fre
RAPID
emergency services.
Q6 note: A mailing address could
include:
street address
postal box (PO Box)
rural delivery details
C/O address.
Q4 note: Please tick one box to show
the title they want to be known by.
Q2 note: Give any other names that
they use now or have used in the
past (including their maiden name).
Before you start
Tax number
1. What is your partners name?
First name(s)
Surname or family name
2. Is your partner known by or used any other names?
No Yes u Please give details below:
1.
2.
3. Are they: Male Female
4. What do they want to be called?
Mrs Miss Ms Mr No title Other
5. Where does your partner live?
Flat/house no. Street name
Suburb City
6. What is their mailing address (if different from above)?
If they live at a rural address please include their rural delivery details here:
7. How can we contact them?
Work phone Home phone Mobile phone
Email Fax
8. What is your partners date of birth?
Day Month Year
9. What is your partners Inland Revenue tax number?
PARTNER CLIENT NUMBER
S02 DEC 2011 9 S02 DEC 2011
Work details 17. Is your partner currently working?
No u Go to Question 21
Yes u Please provide their employers details below:
Employers name
Business site address
Work phone Fax
18. How many hours a week, including lunch hours, does your partner spend at work?
19. How many hours a week does your partner spend
travelling from the centre to work and returning?
20. What is your partners gross weekly wage? $
Residency
Q10 note: Tick one box.
Ethnic group
Q16 note: You dont have to answer
this question if you dont want to.
This information is for statistics and
will be used for research and future
development work.
Q14 note: This means that they
consider New Zealand their home,
they are a legal resident, usually live
here and intend to stay permanently.
16. To what ethnic group does your partner believe they belong?
New Zealand Maori u Which tribe(s)/iwi?
New Zealand European Niuean Samoan Indian
Other European Tokelauan Tongan Chinese
Cook Island Maori Other u Please specify below:
10. Indicate which describes your partners residency situation:
New Zealand citizen (by birth) u Go to Question 14
Date of citizenship
New Zealand citizen (other) u Go to Question 12
Day Month Year
Date permanent residence granted
Permanent resident u Go to Question 12
Day Month Year
Other u Go to Question 11
11. What is your partners residency status?
12. When did your partner arrive in New Zealand?
Day Month Year
13. Where were they born?
14. Does your partner usually live in New Zealand? No Yes
15. Has your partner lived in any countries outside New Zealand? No Yes
S02 DEC 2011 10 S02 DEC 2011
21. Is your partner doing activities arranged for them by Work and Income?
No u Go to Question 25 Yes
22. What type of activities are they doing?
23. How many hours a week does your partner spend at that activity?
24. How many hours a week does your partner spend
travelling from the centre to the activity and returning?
25. Is your partner on a work-related course or studying?
Yes No u Go to Obligations on page 11.
26. Which organisation provides the course?
27. What is the name of their course?
28. Is the course NZQA accredited?
No Yes
29. When does the course start?
Day Month Year
30. When does the course fnish?
Day Month Year
31. How many hours a week does your partner spend at the course?
32. How many hours a week does your partner spend on other study?
33. How many hours a week does your partner spend
travelling from the centre to the course and returning?
Offcial Training Providers stamp
Activity details
Education
Trainers statement
This information is required under
section 12 of the Social Security
Act 1964.
I confrm that the above course details are true and complete.
Trainers name
Organisation
Organisation address
Work phone Fax
Trainers signature Date
Day Month Year
S02 DEC 2011 11 S02 DEC 2011
Obligations
I must tell Work and Income immediately if either my partner or I:
have a change in work situation
become self employed / start to run a business
have changes to my/our income or fnancial circumstances
intend to travel overseas
start / fnish part-time or full-time study
have changes to personal details (such as name, address or bank account details)
have changes to my/our living situation
am imprisoned / held in custody on remand
am admitted to or discharged from hospital
have been granted an overseas pension
have any other changes that may affect my/our beneft entitlement or rate.
I agree that:
I have completed all the questions in this Childcare and OSCAR Subsidy Application (or this
form has been completed for me), and the information I have given is true and complete.
The conditions for receiving this subsidy have been explained to me and I understand these
conditions and my obligations.
I am aware of and understand the Privacy Act statement contained in this form.
Obligations
Work situation changes include
starting part-time, casual or full-
time work, whether paid or unpaid.
Changes in your living situation
include:
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.
Clients name (print) Clients signature Date
Day Month Year
Partners name (print) Partners signature Date
Day Month Year
S02 DEC 2011 12 S02 DEC 2011
Part B Childcare Service Supervisor To Complete
Information for the
childcare service
For more information, please read
our brochure Do you provide
childcare or OSCAR services?.
This form needs to be completed by the childcare service supervisor. The information you
provide will help us to assess if the applicant is eligible for the Childcare Subsidy.
Childcare services include:
family daycare centres
home-based childcare services
Te Kohanga Reo.
Childcare services also include some fee paying:
kindergartens
playcentres.
Childcare service
details
1. What is the name of your childcare service?
2. How can we contact you?
Work phone Home phone Mobile phone
Email Fax
3. Is your centre licensed or chartered by the Ministry of Education?
Yes u You may be asked to provide proof.
No u Please call
%
0800 559 009 and ask for your local Childcare Coordinator.
4. What is your Work and Income childcare service number?
5. Does your childcare service offer 20 Hours ECE?
Yes No
6. Please provide details of childcare provided.
Childs full name
1.
Hours of care Hours of 20 Hours ECE Date they Your hourly fee Total weekly fee
(weekly total) received (weekly total) started care (before subsidy) (before subsidy)
/ / $ $
Childs full name
2.
Hours of care Hours of 20 Hours ECE Date they Your hourly fee Total weekly fee
(weekly total) received (weekly total) started care (before subsidy) (before subsidy)
/ / $ $
Childs full name
3.
Hours of care Hours of 20 Hours ECE Date they Your hourly fee Total weekly fee
(weekly total) received (weekly total) started care (before subsidy) (before subsidy)
/ / $ $
Childs full name
4.
Hours of care Hours of 20 Hours ECE Date they Your hourly fee Total weekly fee
(weekly total) received (weekly total) started care (before subsidy) (before subsidy)
/ / $ $
Note: If you offer 20 Hours ECE you cant charge a fee for those hours. The Childcare Subsidy cannot be used to
cover any donations or optional charges that may be asked.
S02 DEC 2011 13 S02 DEC 2011
7. If your centre closes, what dates are you closed for?
End of Term 1 Closed from: Reopens:
Day Month Year Day Month Year
End of Term 2 Closed from: Reopens:
Day Month Year Day Month Year
End of Term 3 Closed from: Reopens:
Day Month Year Day Month Year
Christmas holidays Closed from: Reopens:
Day Month Year Day Month Year
Other holidays Closed from: Reopens:
Day Month Year Day Month Year
8. Do you charge a holding fee for absences or over the school holidays?
No Yes
Supervisors
statement
This information is required under
section 12 of the Social Security Act
1964.
The information I have given is true and complete.
Supervisors name (print) Supervisors signature Date
Day Month Year
Childcare service
details continued
S02 DEC 2011 14 S02 DEC 2011
Part C OSCAR Programme Supervisor To Complete
This form needs to be completed by the OSCAR programme supervisor. The information you
provide will help us to assess if the applicant is eligible for the OSCAR Subsidy.
OSCAR programmes are for children under 14 years of age (or 1418 years of age if they
receive the Child Disability Allowance) and include:
before and after school care
school holiday programmes.
Information for the
OSCAR programme
service
For more information, please read
our brochure Do you provide
childcare or OSCAR services?.
CLIENT NUMBER
1. Which terms and holiday programmes are you applying for?
Term 1 Term 2 Term 3 Term 4
Holiday Holiday Holiday Holiday
Programme Programme Programme Programme
2. What is the programme name?
3. How can we contact you?
Work phone Home phone Mobile phone
Email Fax
4. Is your programme approved by the Ministry of Social Development?
Yes u Please attach a copy of your Ministry of Social Development approval (if you havent already
provided).
No u Please call
%
0800 559 009 and ask for your local Childcare Coordinator.
5. What is your Work and Income OSCAR provider number?
6. Please provide details of OSCAR care provided.
Childs full name
1.
Hours of care Date they Date they Your hourly fee Total weekly fee
(weekly total) started care ended care (before subsidy) (before subsidy)
/ / / / $ $
Childs full name
2.
Hours of care Date they Date they Your hourly fee Total weekly fee
(weekly total) started care ended care (before subsidy) (before subsidy)
/ / / / $ $
Childs full name
3.
Hours of care Date they Date they Your hourly fee Total weekly fee
(weekly total) started care ended care (before subsidy) (before subsidy)
OSCAR programme
details
S02 DEC 2011 15 S02 DEC 2011
/ / / / $ $
7. If the care is for school holidays, is the parent paying in advance?
No Yes u Part payment in advance: $
8. Do you charge a holding fee for absences or over the school holidays?
No Yes
Supervisors
statement
This information is required under
section 12 of the Social Security Act
1964.
The information I have given is true and complete.
Supervisors name (print) Supervisors signature Date
Day Month Year
OSCAR programme
details continued
S02 DEC 2011 16
OffICE USE ONLY
Checklist
Application entered into UCVII
Does the client receive Child Disability Allowance?
Payments
Processing offcer to complete. Note if the centres fee is less then the subsidy rate, just pay the centre fee.
Childs full name Weekly subsidy Start date End date
Grant Childcare Subsidy before and after school
$ / / / /
$ / / / /
$ / / / /
$ / / / /
$ / / / /
Grant OSCAR Subsidy out of school
$ / / / /
$ / / / /
$ / / / /
$ / / / /
$ / / / /
Grant OSCAR Subsidy school holidays
$ / / / /
$ / / / /
$ / / / /
$ / / / /
$ / / / /
Decision
Granted Declined
Comments
Processors signature Authenticators signature Date
Day Month Year
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