residential care subsidy application rsu01 sample.pdf

Residential Care Subsidy
application
If you need to be in a rest home or private hospital indefinitely, a Residential Care Subsidy may be able to pay
for some of your care. It’s paid directly to the rest home or hospital.
Before you send in this application your needs assessor will complete the Needs Assessment Certificate in this
form. They’ll confirm the level of care you need and that you’re eligible to apply.
There are also some other conditions you need to meet, including:
•  you need to be 65 years old or more, or
•  50-64 years and single with no dependent children.
If you want to know more, go to our website workandincome.govt.nz and search on Residential Care Subsidy.
Information is also in our Residential Care Subsidy Brochure or you can call us on 0800 999 727.
90 Days: You need to apply no more than 90 days after the date you want the Residential Care Subsidy to start.
This application is made up of a number of forms. You might not need to fill them all in, but
we’ll direct you through the form to make sure you’ve completed everything you need to.
What’s in this
Privacy Statement
Page 2
Information about your privacy and how we protect the
application
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information you and others give us.
Needs Assessment  Pages 3–4
This form should be completed by the co-ordinator of your
Certificate
Needs Assessment Service
Financial Means
Pages 5–18
This is the main part of the application. We use the information
Assessment
you give us to work out if you can get Residential Care Subsidy.
Residential Care
Page 19
If you want to keep your home for a while to allow you to adjust
Loan form
to your new circumstances, but there are limited funds to pay
for the cost of your Residential Care, we may be able to help with
a Residential Care Loan.
Helper, Agent or
Page 20–21
This page lets us know if you have a representative for your
Sample O
Sample O
Power of Attorney
dealings with us. We can only share information with an Agent or
form
Power of Attorney.
Appointment of
Page 22–24
If you don’t have an Enduring Power of Attorney and want
agent form
someone to act for you when dealing with us, you need to
complete this form. We need to know what the person or
organisation is authorised to do for you.
Declaration and
Page 25
Where you agree to some conditions and sign your application.
Signature Page
Checklist
Page 26–27
Use this to check you’ve done everything you need to and have
gathered all the documents we need, before you send your form
to us.
Once you’ve completed your form, and gathered all the documents we need, you can:
What you
•  Send your application and documents to us:
Post
Courier
need to
Centralised Processing Services
Centralised Processing Services
do next
Residential Subsidy Unit
Level 2, Rathbone Business Centre
Private Bag 9032
49–53 James Street
Whangarei 0148
Whangarei 0110
•  Take it to any of our offices. We’ll copy and send your documents to our processing unit
•  Scan and email your documents to [email address]
RSU01 – Nov 2023
Page 1

How we protect your
privacy

Collecting your information
We collect your personal information, so we can provide income support, NZ Super or veteran’s Pension, Student
Allowance, or Loans and connect you with employment, education and housing services. We do this under various
Acts, which are all listed on our website at workandincome.govt.nz/privacy
•  To help us do this, we collect information about your identity, your relevant history, and your eligibility for our services.
•  We get this information directly from you, and we sometimes collect information about you from others, including other
government agencies.
•  You can choose not to give us your personal information, but we might not be able to help you if you don’t.
Using your information
We use the information you give us to make decisions about the best way to help you.
•   These decisions may be about:
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– whether you’re eligible for our services

– running our operations and ensuring our services are effective

– the services we’ll provide in the future.
Sharing your information
Sometimes, we need to share your information outside our Ministry to reach our goal of helping New Zealanders
to be safe, strong, and independent.
•  To do this, we may share your information with:

– prospective employers to help you find work
Sample O
Sample O

– contracted service providers that help us to help you

– health providers if we need your medical information to assess your eligibility

– other government agencies when we have an agreement with them

– some other governments if you may be eligible to get or are getting an overseas pension.
•  We also share personal information when the law says we have to.
Respecting you and your information
We make sure we follow the Privacy Act to do what’s right when we use your information.
•  We treat you and your information with respect, by acting responsibly and being ethical.
•  We make sure any technology we use meets strict security standards so it keeps your information safe.
Get in touch if you have a question
You have a right to ask to see your personal information, and to ask for it to be corrected if it’s wrong.
•  If you have a question or a complaint, please get in touch.
•   You can find full details about what we do with personal information in our privacy notice at:
workandincome.govt.nz/privacy
Page 2
RSU01 – Nov 2023

Residential Care Subsidy
needs assessment certificate
This form should be completed by the co-ordinator of a Needs Assessment Service.
This form should stay with the main application and not be separated.
Client’s
1
What is the client’s full name?
details
First and middle names
Surname or family name
2
What is the client’s date of birth?
Day
Month
Year
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3
Is the person aged 50-64 years, single with no dependent children?
No
Yes
Go to question 5
4
Is the person aged 65 years or more?
No
The person won’t qualify for Residential Care Subsidy at this time
Sample O
Sample O
Yes
INFoRMATIoN FoR Q5:
5
Is the person eligible for publicly funded health and disability services?
It’s important you
check whether your client
No
The person won’t qualify for Residential Care Subsidy at this time
is eligible for publicly
funded health services.
Yes
6
Has the person been assessed by a needs assessor as requiring long-term
residential care in a hospital or rest home, indefinitely?
No
The person won’t qualify for Residential Care Subsidy at this time
Yes
More questions over the page
RSU01 – Nov 2023
Page 3

Needs
7
Who has undertaken the assessment?
assessment
Name of assessor
information
Assessment team
8
What was the date of the needs assessment?
Day
Month
Year
Service
9
Who is the service provider?
provider
Name of hospital or rest home
details
Address of hospital or rest home
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10
What date did/will the person enter the rest home or hospital?
Day
Month
Year
11
What is the Territorial Local Authority?
Service co-ordinator’s statement
Sample O
Sample O
Based on the answers to questions 3-6 above, I confirm the person meets the criteria for a Financial Means
Assessment to be completed.
Service co-ordinator’s agency
Agency’s address
Email
Contact phone
Service co-ordinator’s name (print)
Service co-ordinator’s name signature
Day
Month
Year
Page 4
RSU01 – Nov 2023

Residential Care Subsidy
financial means assessment
As you answer the questions, look for the Attachment icon in the margin. When you see these, you may
need to provide some documents. We also have a checklist to help you at the end of the form.
Please initial any changes that you make.
Tell us about yourself
If you get New Zealand Superannuation, Veteran’s Pension, a benefit or extra financial help from Work and
Income or have done in the past, write your client number here if you know it. This number can be found on
your SuperGold Card or Community Services Card if you have one.
Client number
Tell us about 1
What is your full name?
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yourself
Mr
Mrs
Ms
Miss
Other
First and middle names
Surname or family name
2
Is the name on your birth certificate the same as above?
No
If no, tell us the name that is on your birth certificate
Yes
Sample O
Sample O
First and middle names
Surname or family name
HoW To ANSWER Q3:
3
Have you ever been known by any other name?
For example, have you
had married names,
No
Yes
If yes, write them all out below
English names, changes
by deed poll, or aliases?
1.
2.
4
What name would you like us to call you?
The name I wrote in Question 1
The name I wrote in Question 2
Other
If other, write the full name
RSU01 – Nov 2023
Page 5

5
What date were you born?
Day
Month
Year
6
Are you:
Male
Female
Gender diverse
Tell us your
7
Tick the group(s) you most identify with.
ethnicity
Māori
Which tribe(s) or iwi?
INFoRMATIoN FoR Q7:
New Zealand
We collect this
European
Niuean
Samoan
Indian
information for statistics
Other European
Tokelauan
Tongan
Chinese
we use in research and
future development work.
Cook Island Māori
Other
If other, write below
Don’t want to answer
Tell us your
8
What was your address before you entered residential care?
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contact details
Flat/House number Street name
HoW To ANSWER Q8:
If you lived in a rural
Suburb
area, flat/house number
could include your RAPID
number, fire number,
Town/City
emergency services
number.
HoW To ANSWER Q9:
9
What address would you like your mail sent to?
Mailing address can
include a PO Box, rural
Sample O
Sample O
delivery details, or
C/O address.
10
What is the name and address of the rest home or hospital where you
currently stay?
Rest home or hospital name
Address of rest home or hospital
11
What date did you enter the rest home or hospital?
Day
Month
Year
Page 6
RSU01 – Nov 2023

Payment
details
If you qualify for a Residential Care Subsidy, most of your NZ Super, Veteran’s
Pension or benefit payments must go towards the cost of your care at the rest
home or hospital.
You keep a personal allowance of a set amount each payday.
12
Do you want us to redirect the contribution from your NZ Super, veteran’s
Pension or benefit directly to your rest home or hospital?
No
You’ll be responsible to pay this yourself
Yes
Payments will start when we’ve decided you’re financially eligible for
Residential Care Subsidy

13
Have you already paid rest home fees?
No
Yes
If yes, what date have you paid your fees up to?
Day
Month
Year
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Tell us
14
Do you have dependent children in your care?
about your
dependent
children
No
Go to page 8
Yes
If yes, please provide details below
Child 1
Date of birth
HoW To ANSWER Q14:
Full name
Day
Month
Year
Please give the names
of children you’re
responsible for, are
Relationship to you
maintained as a member
Sample O
Sample O
of your family and you
support financially.
Parent 1: Full name
Parent 2: Full name
Child 2
Date of birth
Full name
Day
Month
Year
Relationship to you
Parent 1: Full name
Parent 2: Full name
If you need to include more than two children, please write these details about
each one on a separate sheet of paper, and provide it with this application form.
RSU01 – Nov 2023
Page 7

Relationship
Whether people are single or a couple affects eligibility for certain income assistance and the rate
status
at which we can pay that assistance.
When we work out your entitlement to income assistance, we’ll consider you to be in a relationship if
you’re married, in a civil union, or in a de facto relationship, and have a degree of companionship.
INFoRMATIoN NoTE:
This definition applies to
By degree of companionship, we mean two people:
your situation now and
•  are committed to each other emotionally for the foreseeable future, and
immediately before you
•  are financially interdependent.
moved to the rest home
To give you a better idea of what we mean by this, think about whether your relationship includes
or hospital.
some of the things below:
•  you live together at the same address most of the time
•  you share responsibilities, for example bringing up children (if any)
•  you socialise and holiday together
•  you share money, bank accounts or credit cards
•  you share household bills
•  you have a sexual relationship
•  people think of you as a couple
•  you give each other emotional support and companionship.
HoW To ANSWER Q15:
15
Do you understand our definition of a relationship for benefit purposes?
Tick this statement
to confirm you
No
Please talk with us
understand the
definition of a relationship
Yes
for benefit purposes.
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16
Do you have a partner?
No
Go to question 27 on page 10
Yes
Go to question 17
17
What is your partner’s full name?
First and middle names
Sample O
Sample O
Surname or family name
18
What is your partner’s date of birth?
Day
Month
Year
19
What is your relationship status with your partner?
Tick one of the following boxes
Married
In a civil union
In a relationship
20
How can we contact your partner?
Tick the best way for us
to contact your partner
Home phone
( )
Mobile phone
( )
Email
Other
Page 8
RSU01 – Nov 2023

Your
21
Where does your partner live?
partner’s
Flat/House number
Street name
living situation
Suburb
Town/City
INFoRMATIoN FoR Q22:
22
What is your partner’s accommodation?
We need to know the
information in this section
House or flat
A room in a boarding house
so we can pay them the
right rate.
Self-contained ‘granny’ flat
Hotel or motel
INFoRMATIoN FoR Q22:
Self-contained unit in a retirement village or rest home
‘Self-contained’ for
a granny flat or unit
Mobile home – self-contained
means there is a kitchen
or a kitchenette and a
bathroom.
A boat moored within New Zealand territorial waters
‘Self-contained’ for a
Accommodation in a caravan park
mobile home means it
needs to have facilities for:
Other
If other, please provide details below
•  day-to-day living
•  sleeping
•  preparing and
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cooking food.
23
Does your partner live alone?
It must also have a:
•  sink
No
Go to question 24
•  toilet
Yes
What date did they start living alone?
Day
Month
Year
•  fresh water tank
•  waste water tank.
Go to question 25
HoW To ANSWER Q24:
We don’t need to
know the name of
24
Please provide details for anyone living with your partner
each person.
Person 1
Relationship to your partner
Sample O
Sample O
Is this person 18 years or younger?
No
Go to next person or question 25
Yes
What is their date of birth?
Day
Month
Year
Does this person attend school or a tertiary institution?
No
Yes
INFoRMATIoN FoR Q24:
Person 2
If you need to include
Relationship to your partner
more people, please write
these details about each
Is this person 18 years or younger?
one on a separate sheet
of paper, and provide it
No
Go to next person or question 25
with this application form.
Yes
What is their date of birth?
Day
Month
Year
Does this person attend school or a tertiary institution?
No
Yes
HoW To ANSWER Q25:
25
Does your partner have visitors aged 18 or older who’ll be staying with them
A visitor is someone
for 13 weeks or longer?
who doesn’t normally live
with your partner.
No
Yes
RSU01 – Nov 2023
Page 9

Choosing
an asset
Information about choosing an asset threshold
threshold
If you’re 65 years or over and have a partner (who is not in care) or dependent
child, the value of your assets must be equal to or below a certain threshold.
If you and/or your partner own a house and your partner and/or a dependent
child are still living there, it won’t be counted as an asset.
There are two asset thresholds. You can choose which one best suits your
circumstances.
Threshold A is the higher threshold and includes the value of your house
and car.
Threshold B is a lower threshold and does not include the value of your house
and car.
To find out the amount of each asset threshold go to our website
www.workandincome.govt.nz and search on the key words Residential Care
Subsidy.
26
Which asset threshold would you like to be assessed under?
Please tick one of the boxes below
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Threshold A
Threshold B
Home
ownership
This section is about the home you and your partner lived in (your principal
place of residence) before you moved to the rest home or hospital.
details
INFoRMATIoN FoR Q27:
Sample O
Sample O
A Licence to Occupy
or Occupation Right
27
Do you or your partner have a ‘Licence to occupy’ or ‘occupation Right
Agreement outlines
Agreement’?
the conditions for
occupying a residential
No
Go to question 28
unit within a retirement
village.
Yes
If yes, what is the current surrender value?
ATTACHMENT FoR Q27:
$
Go to question 37
You’ll need to provide
proof of the current
surrender value. You
can get this from your
Village Manager.
INFoRMATIoN FoR Q28:
28
Do you or your partner own your own home?
Owning your own
home includes:
No
Go to question 36
•  apartment
•  studio unit
Yes
If yes, what is the address of the property?
•  cottage.
Flat/House number
Street name
Suburb
Town/City
Page 10
RSU01 – Nov 2023

ATTACHMENT FoR Q29:
29
What is the capital value of the property?
Please provide your
latest QV Valuation or
$
rates demand that shows
the capital value.
30
Do you have a mortgage on your home?
ATTACHMENT FoR Q30:
Please provide proof
No
Yes
If yes, what amount is still owing on your home?
of the mortgage and the
amount still owing on it.
$
31
Who’ll be living in your home while you’re in the rest home or hospital?
The home will be empty
My partner
The home will be rented out
My dependent child
Someone will be living there but they won’t be paying rent
Please explain why they won’t be paying rent
32
Is your home currently rented out?
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No
Go to question 38
Yes
33
How much rent do you charge for your home each week.
$
ATTACHMENT FoR Q34:
34
What are your home ownership costs?
You’ll need to
How often do you make the
Sample O
Sample O
provide proof of your
How much do
payment (such as weekly,
home ownership costs.
Who do you pay?
you pay?
monthly or yearly)?
Mortgage 1
$
Mortgage 2
$
House insurance
$
Mortgage insurance
$
Rates
$
Ground lease
$
Water rates
$
Body corporate fees
$
Property
management fees
$
RSU01 – Nov 2023
Page 11

ATTACHMENT FoR Q35:
35
Did you have to pay for repairs or maintenance to your home in the past
Please provide receipts
12 months?
for any repair and
maintenance costs.
No
Yes
Please write the total amount
$
Go to question 38
ATTACHMENT FoR Q36:
36
Who owns the home you were living in?
Please provide a copy
of the Will if the home
A landlord
Other family members
is owned or part owned
by an estate you have
A trust
An Estate (Please see the attachment note)
involvement with, for
example as a beneficiary
A retirement village
or executor.
Other
If other, please tell us who owns the property
37
Have you ever owned a home?
No
Yes
If yes, when was the home sold?
Day
Month
Year nly
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Tell us
38
Do you or your partner have any of the following cash assets?
about
your assets
Money in the bank or other savings
No
Yes
Term deposits, investments or shares
No
Yes
HoW To ANSWER Q38:
This includes all overseas
Bonds
No
Yes
accounts and assets.
Life insurance policies with a surrender or cash value
No
Yes
ATTACHMENT FoR Q38:
You need to provide
Loans made to other people (including family trusts)
No
Yes
proof of all your and your
Sample O
Sample O
partner’s assets and their
Life interest in a property, family trust or estate
No
Yes
value.
Other cash assets
No
Yes
! Important: You MUST answer question 39 if you ticked any of the ‘Yes’
boxes in question 38.
ATTACHMENT FoR Q39:
39
If you answered ‘yes’ to any of the assets listed in Question 38, please write
You need to include
the details below.
proof of:
Interest
•  all bank accounts
Type of asset
You
Your partner
Jointly owned
rate
and their full balances,
$
$
$
%
including accounts
and other assets held
$
$
$
%
overseas
$
$
$
%
•  the current interest rate
% payable on all your
$
$
$
%
assets.
$
$
$
%
$
$
$
%
$
$
$
%
$
$
$
%
Page 12
RSU01 – Nov 2023

ATTACHMENT FoR Q40:
40
Do you or your partner have a pre-paid funeral trust fund or account?
You’ll need to
provide a copy of
No
Go to question 41
Yes
If yes, please write the details below
your pre-paid funeral
certificate.
You
When did you open it?
Who is it with?
Day
Month
Year
How much was it for when you opened it?
How much is it worth now?
$
$
Your partner
When did you open it?
Who is it with?
Day
Month
Year
How much was it for when you opened it?
How much is it worth now?
$
$
HoW To ANSWER Q41:
41
Do you or your partner have any of the following non-cash assets?
Examples of property
include, land, holiday
Property (other than your family home)
No
Yes
homes, bach/crib,
investment properties
Motorhome, caravan or boat
No
Yes
and overseas property.
Motor vehicle
No
Yes
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Other
No
Yes
! Important: You MUST answer question 42 if you ticked any of the ‘Yes’
boxes in question 41.
ATTACHMENT FoR Q42:
42
If you answered ‘yes’ to any of the non-cash assets listed above,
You need to provide
please write the details below.
proof of these assets
including the insured
How much is it
How much do you
value of any motor
Type of asset
worth?
owe on it?
vehicles.
$
$
Sample O
Sample O $
$
Tell us about 43
Have you or your partner sold any assets in the last five years?
assets you’ve
No
Yes
If yes, please provide details below
sold
Asset 1
HoW To ANSWER Q43:
Please include assets
What was the asset?
How much was it sold for?
sold to a trust, family
$
members, business or
charitable organisations.
When was it sold?
Who was it sold to?
Day
Month
Year
INFoRMATIoN FoR Q43:
Depending on your
circumstances we may
ask you for information on
assets sold more than five
Asset 2
years ago.
What was the asset?
How much was it sold for?
ATTACHMENT FoR Q43:
$
You’ll need to provide
proof of the sale of the
When was it sold?
asset, like a solicitor’s
Who was it sold to?
Day
Month
Year
settlement statement.
RSU01 – Nov 2023
Page 13

Tell us about
assets you or
Gifting assets includes giving away, transferring, or disposing of your assets to
another person or organisation.
your partner
have gifted
If you or your partner (even if they have died) have given assets away they may
still be counted for this assessment.
You can gift up to a certain amount for each year before you apply. To find
out the amount you can gift go to our website workandincome.govt.nz and
search Residential Care Subsidy.
INFoRMATIoN FoR Q44:
44
Have you or your partner ever gifted any assets?
Depending on your
circumstances, we may
No
Yes
If yes, please provide details below
ask you for information on
assets gifted more than
five years ago.
Asset 1
HoW To ANSWER Q44:
What was the asset?
What was the asset worth?
Please include assets
$
gifted to a trust, family
members, business or
When was it gifted?
charitable organisations.
Who was it gifted to?
Day
Month
Year
ATTACHMENT FoR Q44:
Please provide proof
nly
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of the assets you gifted.
If you can’t do this you’ll
need to talk with us.
Asset 2
What was the asset?
What was the asset worth?
$
When was it gifted?
Who was it gifted to?
Day
Month
Year
Asset 3
Sample O
Sample O
What was the asset?
What was the asset worth?
$
When was it gifted?
Who was it gifted to?
Day
Month
Year
ATTACHMENT FoR Q44:
If you have given away
Asset 4
more assets, please write
these details about each
What was the asset?
What was the asset worth?
one on a separate sheet
$
of paper.
When was it gifted?
INFoRMATIoN FoR Q45:
Who was it gifted to?
Day
Month
Year
A high level of care is
the care provided to you
that enables you
to remain in the
45
Have you received a high level of care from someone other than your partner
community without
or dependent child and gifted in recognition of that care?
receiving home-based
disability services. For
No
Yes
more information go to
workandincome.govt.nz
and search Recognition
of Care.
Page 14
RSU01 – Nov 2023

Are you
46
Are you or your partner (including any partner who has died) involved in a
involved
trust, or have you ever been involved in a trust?
with a trust?
The trust can be any type of trust, including a family trust.
ATTACHMENT FoR Q46:
‘Involved’  means one or more of the following:
You’ll need to provide
full copies of trust
•  you’ve set up a trust, usually by making a gift of assets or property
documents; such as:
•  you’ve sold or gifted assets to a trust
•  trust deed
•  deeds of
•  you make decisions about managing a trust
acknowledgment of
debt
•  you benefit from a trust; for example, by receiving income or assets from the
•  deeds of forgiveness
trust or free or subsidised accommodation.
of debt
If you are a beneficiary of a trust you are entitled to ask the trust for financial
•  Inland Revenue gifting
support, and the Ministry of Social Development considers it reasonable for you
statements
to do so. The trust may decide to distribute assets to you, or it may decide to
•  the latest trust financial
make regular payments. If the trust won’t support you, they’ll need to tell us why.
statements.
No
Go to question 50
Yes
If yes, please write the name of the trust
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! Important: You MUST answer question 47 if you ticked ‘Yes’ for question 46.
INFoRMATIoN FoR Q47:
47
Have you or your partner received financial support from the trust in the past?
Financial support
can include getting
No
Go to question 49
Yes
Go to question 48
assets, income or
free or subsidised
accommodation.
48
What type of financial support did you get?
Regular payments (also known as Distribution of Beneficiary Income)
Sample O
Sample O How often, eg weekly,
How much are you paid?
Last payment date?
fortnightly, monthly, etc
$
Lump sum (also known as Distribution of Trust Assets)
How much was paid?
When was it paid?
$
Free or subsidised accommodation
INFoRMATIoN FoR Q49:
49
Will you or your partner get financial support from the trust?
Before we decide your
Tick and answer all that apply.
application you must ask
How often, eg weekly,
the trust for support, and
How much?
fortnightly, monthly, etc
you will need to give us
Yes, the trust will pay a lump sum of
$
proof of their response,
like a letter from the
Yes, the trust will pay regular payments of
trustees.
$
No
If no, please tell us why the trust won’t be financially supporting you
RSU01 – Nov 2023
Page 15

Estate
50
Have you or your partner ever been the beneficiary of an estate?
information
No
Go to question 58
Yes
51
What is the name of the estate?
INFoRMATIoN FoR Q52:
52
Have you or your partner inherited money or other assets or received
Financial support
financial support from the estate in the past 10 years?
can include getting
assets, income or
No
Go to question 57
free or subsidised
accommodation.
Yes
ATTACHMENT FoR Q52:
You’ll need to provide 53
How was the amount paid to you?
proof of your
inheritance if it was
Lump sum
Go to question 54
recent and more than
a modest amount. For
Regular payments
Go to question 55
example, a copy of the
Will and the latest
nly
nly
estate accounts if
54
Please tell us about the lump sum payment.
you get regular or
ongoing payments.
How much was it?
$
What date was it paid?
Day
Month
Year
Go to question 57
ATTACHMENT FoR Q55:
55
Have the regular payments stopped?
You’ll need to provide
proof of your payments.
No
Go to question 57
Sample O
Sample O
Yes
If yes, how much did you usually get paid?
$
How often, eg weekly, fortnightly, monthly, etc
When was the last payment?
Day
Month
Year
56
Why have the payments stopped?
! Important: Before you answer question 57, you MUST read the
information for Q57 in the margin.
Page 16
RSU01 – Nov 2023

INFoRMATIoN FoR Q57:
57
Will you or your partner get financial support from the estate?
Before we decide your
Tick and answer all that apply.
application you must
How often, eg weekly,
ask the estate for
How much?
fortnightly, monthly, etc
support. You’ll need to
Yes, the estate will pay a lump sum of
$
give us proof of their
response, like a letter
Yes, the estate will pay regular payments of
from the executor and a
$
copy of the latest estate
No
accounts.
If no, please tell us why the estate won’t be financially supporting you
outstanding  58
What outstanding debts do you have?
debts
Type of debt
Money owing
$
ATTACHMENT FoR Q58:
You’ll need to
$
provide proof of those
$
debts if they are more
than $500.
$
nly
nly
Tell us if you’re
involved in a
A business you’re involved in can be:
business
•  A sole trader
•  A partnership
•  A company.
ATTACHMENT FoR Q59:
59
Have you or your partner had any assets or financial involvement in any
You must provide the
business in the past 10 years?
latest complete set of
Sample O
Sample O
business accounts for
No
Go to question 63
each business.
Yes
INFoRMATIoN FoR Q59:
If you’re involved
in more than one
60
What is the name of the business?
business please
provide all this
information for the other
business on a separate
sheet of paper.
61
How are/were you involved in the business?  Please tick all that apply
Director
Shareholder
Employee
Other
If other, please describe below
62
Are you still involved in the business?
Day
Month
Year
No
What date did your involvement end?
Yes
RSU01 – Nov 2023
Page 17

Tell us about your income
Tell us
63
Did you or your partner get income from any of the following sources in the
about
last 52 weeks?
income
Interest from savings, investments, or bonds
No
Yes
in the last
Dividends from shares, unit trusts, or managed funds
No
Yes
52 weeks?
Overseas pension , benefit or allowance payments
No
Yes
HoW To ANSWER Q63:
Other superannuation or retirement scheme income
Don’t include payments
(government or private)
No
Yes
from Work and Income
like, NZ Super or benefits.
Income from rents
No
Yes
Child Support payments (private arrangement or through Inland Revenue)
No
Yes
Wages or salary
No
Yes
Farm or business income
No
Yes
Payments from self employment or contract work
No
Yes
Accident compensation (eg ACC)
No
Yes
Income from relatives
No
Yes
nly
nly
Payments from a former partner
No
Yes
Income insurance (replacement/protection)
No
Yes
Income from Māori Land
No
Yes
Other
No
Yes
! Important: You MUST answer question 64 if you ticked any of the
‘Yes’ boxes in question 63.
Sample O
Sample O
ATTACHMENT FoR Q64:
64
Did you answer ‘yes’ or to any of the sources of income listed in question 63?
You need to provide
proof of all income.
No
Yes
If yes, tell us the total before-tax amounts, for the last 52 weeks
Payment made to?
Where did the income come from?
You
Your partner
How often?
$
$
$
$
$
$
$
$
$
$
65
Do you or your partner expect to get the same or similar income from all
these places in the next 52 weeks?
No
If no, what will be changing or different?
Yes
Page 18
RSU01 – Nov 2023

Residential Care Loan
application
If you need to be in a rest home or private hospital indefinitely and still have your own home, you may need
time to adjust to your changed circumstances. This may include selling your home. Often this means there are
limited funds to pay for your residential care fees.
We may be able to help with an interest-free Loan to pay your fees. It’s a legal agreement with the Crown and is
secured by placing a caveat over your home.
The Loan is usually repaid when your home is sold or you die – whichever happens first.
There’s much more information on our website workandincome.govt.nz – search Residential Care Loan.
We recommend that you read the information and call us on 0800 999 727 if you want to know more.
Do you need 1
Do you need to apply for a Residential Care Loan?
to apply?
No
Go to page 20
Yes
You must complete pages 5 to 18 of this form
Mailing
2
If a loan is approved, what address would you like your loan balance
nly
nly
details
statements sent to?
3
Do you have a partner?
No
Go to question 5
Yes
4
Is the loan application for both you and your partner?
Sample O
Sample O
No
Yes
Legal details 5
Who will legally act for you?
Solicitor’s name
Solicitor’s address
Solicitor’s contact details
Phone
( )
Mobile phone
( )
Email
6
What property will secure the loan?
Address of property
RSU01 – Nov 2023
Page 19

Residential Care Subsidy
Helper, Agent or Power of
Attorney form
We need to know if someone has helped you complete this form. We also need to know if you have, or want
to have, an agent or Power of Attorney to represent you or help you deal with us in future. If so, you’ll need to
confirm their details for us on this form.
Protecting your privacy is important and we must have your written permission for other people to do things
with us on your behalf, such as making enquiries or filling in forms for you. By answering the following questions,
we’ll have a clear understanding of what other people can or can’t do for you if they contact us.
Helper, Agent 1
Do you have someone helping you complete this form?
or Power of
No
Go to page 22
Attorney’s
details
Yes
If yes, what type of representative are they?
An agent I have already set up with the Ministry of Social Development
INFoRMATIoN FoR Q1:
An agent is a person or
organisation you’ve asked
Enduring Power of Attorney for Propertynly
nly
to act on your behalf when
dealing with the Ministry of
Power of Attorney for Property
Social Development.
Court appointed Property Manager
ATTACHMENT FoR Q1:
You must provide the Power
Helper
of Attorney for Property or
Court ordered
Property Manager.
2
Who is your representative?
A person
Go to question 3
An organisation
Go to question 7
Sample O
Sample O
INFoRMATIoN FoR Q3:
3
What are your representative’s details?
We’ll check our record
of your representative’s
First and middle names
details is up-to-date.
We need to make sure your
Surname or family name
agent is over a certain age.
When were they born?
What is their relationship to you?
Day
Month
Year
4
What is your representative’s address?
Flat/House number
Street name
Suburb
Town/City
Page 20
RSU01 – Nov 2023

5
Is your representative’s mailing address different from where they live?
No
Yes
If yes, tell us your representative’s mailing address
HoW To ANSWER Q6:
6
How else can we contact your representative?
Tick the best way for us to
Please only give us
contact your representative
contact details your
Home phone
( )
representative would like
us to use.
Mobile phone
( )
Other phone
( )
Email
INFoRMATIoN FoR Q7:
7
What are the organisation’s details?
We’ll check our record
of your organisation’s
Name of organisation
details is up-to-date.
Address of organisation
Contact person’s name
Contact person’s phone
Email address
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Sample O
Sample O
RSU01 – Nov 2023
Page 21

Appointment of an agent
form
You can apply for another person or organisation to officially act on your behalf for specific services and
functions with the Ministry of Social Development.
You can choose your agent and decide what they can or can’t do. They can be a person or an organisation.
However, whoever you choose must agree to act on your behalf.
You can change or stop your arrangement with your agent at any time by contacting us. You should also let your
agent know that you no longer want them to act for you.
We have more information on our website about appointing an agent. Go to workandincome.govt.nz and
search on Agent.
Tell us if
1
Do you want to appoint a person or organisation to officially act for you with
you’re
the Ministry of Social Development?
appointing an
I already have one set up Go to the Declaration and Signature on page 25
agent
No
Go to the Declaration and Signature on page 25
Yes
nly
nly
2
Who do you want to appoint as your agent?
A person
Go to question 3
An organisation
Go to question 7
ATTACHMENT FoR Q3:
3
What are your agent’s details?
Please provide proof
of your agent’s identity.
First and middle names
What you need is explained
on page 27.
Sample O
Sample O
Surname or family name
When were they born?
What is their relationship to you?
Day
Month
Year
4
What is your agent’s address?
Flat/House number
Street name
Suburb
Town/City
5
Is your agent’s mailing address different from where they live?
No
Yes
If yes, tell us your agent’s mailing address
Page 22
RSU01 – Nov 2023

HoW To ANSWER Q6:
6
How else can we contact your agent?
Tick the best way for us to
Please only give us
contact your representative
contact details your agent
Home phone
( )
would like us to use.
Mobile phone
( )
Other phone
( )
Email
INFoRMATIoN Fo R Q7:
7
What are the organisation’s details?
We’ll check our record
of your organsation’s details
Name of organisation
is up-to-date.
Contact person’s name
Address
Phone number
( )
Email
Tell us how
8
How long do you want to have this agent for?
long you want
No end date – this person will be your agent until you tell us.
an agent for
Day
Month
Year
nly
nly
Until
Tell us what
9
What rights and responsibilities do you want to give your agent?
you want your
(Please tick the boxes that apply)
agent to be
Access to my files to get personal information about me.
able to do
Give information about me to the Ministry of Social Development, such as income details,
housing need or changes in my circumstances.
INFoRMATIoN FoR Q9:
You can give your
Change details in my personal file with the Ministry of Social Development.
agent as many or as few
Sample O
Sample O
rights and responsibilities
Receive all my mail from the Ministry of Social Development.
as you want. For example,
“my agent can only speak
Complete and sign forms on my behalf.
or make enquiries about
my Residential Care
Be allowed to deal with money I owe the Ministry of Social Development, which may include
Subsidy”.
arranging repayments.
Have authority over my affairs with the Ministry of Social Development, as granted by a current
ATTACHMENT FoR Q9:
Please provide the
Power of Attorney.
Power of Attorney if you
Speak or make enquiries on my behalf.
have one.
Speak to social housing providers about a potential property match or offer.
Paying your benefit or pension to an agent
If you want your agent to get paid part or all of your benefit or pension payments you’ll need to
complete a redirection of benefit payment form.
10
Is there anything else you want your agent to do?
No
Yes
If yes, please tell us below
RSU01 – Nov 2023
Page 23

11
Is there anything you don’t want your agent to do?
No
Yes
If yes, please tell us below
12
Did you fill in this form yourself
No
Go to question 13
Yes Make sure your agent signs this page at the bottom, then go to the Client’s
Declaration on page 25
Client unable  13
Why are you completing this form for your client?
to sign this
form
If the client is unable to sign this form, and the form is being completed on
their behalf by a person wishing to be appointed their agent, please tick the
ATTACHMENT FoR Q13:
reason for this.
Attach a copy of either
the Enduring Power of
I have authority over this client’s affairs, as covered by the attached valid Enduring Power of
Attorney or Court Order.
Attorney or Court Order made under the Protection of Personal and Property Rights Act 1988.
Attach evidence from
nly
nly
a registered medical
This client is temporarily unable to do things for themself, and I wish to be appointed their
practitioner. This needs to
agent for a short period of time to enable the Ministry of Social Development to meet the
state the reason why
client’s immediate needs.
the client can’t act
for themself and
how long it is likely
to last.
14
What is your relationship to this client?
HoW To ANSWER Q14:
Please tell us what your
relationship is with the
client, for example, partner,
friend, family member or
support person.
Sample O
Sample O
Agents must read and sign this section.
Agent’s
declaration
and signature
By signing this form you, or the organisation you represent:
•  agree to act as agent for the person named in this application
Acting in the person’s
•  understand the responsibilities the person has given
best interests includes:
•  will always act in the person’s best interests
•  talking to them about
•  agree to receive emails from the Ministry of Social Development about the person
their needs and what
they expect
•  will let the Ministry of Social Development know if your address or contact details change
•  making sure they get
•  can’t access the person’s MyMSD account (if they have one)
everything they’re
•  have read and understand the Privacy Statement on page two of this form
entitled to
•  understand the person still has full responsibility for all matters with the Ministry of Social Development
•  letting MSD know
•  can stop being this person’s agent, but must let the client and the Ministry of Social Development know.
about changes in their
circumstances.
The information I have provided is true and complete.
Agent’s name (print)
Agent’s signature
Day
Month
Year
! Important: Please make sure the application is signed on page 25.
Page 24
RSU01 – Nov 2023

Declaration and Signature
Let us know when things change
Applicant’s
You need to let us know about changes that might affect the amount you’re paid, or your
Residential Care Subsidy or Loan, like:
or agent’s
•  changes to your income or assets
declaration
•  changes to information about you, like your address, contact details or bank account number
and signature
•  you go into or come out of hospital
•  starting or ending a relationship, marriage or civil union
•  if a partner passes away
•  you travel overseas.
If we have the wrong information we could pay you or the Residential Care Subsidy or Loan at the
wrong amount. If we pay you too much you might have to pay us back.
Sharing your information
We explain how we protect your privacy in our Privacy Statement on page two of this form.
If you get a Residential Care Subsidy, the Ministry of Social Development and Ministry of Health
nly
nly
need to:
•  share information necessary to pay and administer your Residential Care Subsidy or Loan
•  provide information to your residential care provider about how your application is going, the outcome
and the timing and amount of any payments we make.
By signing this form
I understand the things I need to do to get a Residential Care Subsidy or Loan. The information I have
provided is true and complete.
Applicant’s/Agent’s name (print)
Applicant’s/Agent’s signature
Day
Month
Year
Sample O
Sample O
Partner’s/Partner’s Agent’s name (print)
Partner’s/Partner’s Agent’s signature
Day
Month
Year
RSU01 – Nov 2023
Page 25

Checklist
Use this page to check you’ve done everything you need to and have gathered all the documents we
need. Attachment notes    in the margins of the form also show if you need to provide some documents.
Talk with us if you don’t have any of the documents, have given them to us recently or if there might be a delay
in getting them. You can call us on 0800 999 727.
For your partner
Documents you may need to give us
For you
(if you have one)
What you
Home ownership documents
may need to
Mortgage documents, showing:
provide
•  the amount still owing
•  how much your repayments are and how often
Other accommodation costs including:
•  house and mortgage insurance
nly
nly
•  rates – showing the capital value or your QV valuation
•  lease
•  body corporate and property management fees
•  repair and maintenance costs
Confirmation of the current surrender value of your Licence to
Occupy or Occupation Right Agreement
Copy of the Will if your home is owned or part owned by an Estate
Assets
Sample O
Sample O
Bank statements or printouts showing balances and transactions
for the last three months, for every account you hold, including
overseas accounts
Proof of all your other assets and income, including the interest
rates on your accounts and investments
Pre-paid funeral account or trust fund certificate
Value of other property you own, including land, holiday homes,
investment properties, motor vehicles, caravans, boats
Proof of sale for assets you’ve sold, gifted or transferred –
including to any trust or family members
Trusts and estates
Trust documents, if you’re involved in a trust (for example, trust
deed, deed of debt, deed of gift, gift statements, accounts)
Proof of any inheritance, for example a Will or the latest estate
accounts if you get regular payments
Income and debts
Proof of all types of income you get
The complete set of the most recent business accounts for any
business you are, or have been involved with in the past 10 years
Proof of any debts that are more than $500
Page 26
RSU01 – Nov 2023

If you already have a Power of Attorney or someone who acts
If someone
on your behalf, you’ll need to provide your:
For you
For your Agent
acts on your
Enduring Power of Attorney for Property
behalf
Power of Attorney
Court Order if the court has appointed a representative
If you want to set up an agent with us
Complete the appointment of agent form
If your agent is a person they need to provide:
Two original documents that prove who they are, such as a driver
licence, passport or birth certificate.
Agents must bring their original documents to one of our offices to
be scanned and given back straight away. Do not send them to us.
If your agent is an organisation, they need to provide a:
Business card, or
Letter on official letterhead – needs to be an original
Last check
For you
Have you
nly
nly
Have you answered all the questions you need to?
done
everything?
Have you signed your application on page 25?
Please initial any changes you’ve made on the form
Has the Needs Assessment Certificate been completed?
Have you gathered the other documents you need to provide?
Sample O
Sample O
RSU01 – Nov 2023
Page 27

nly
nly
Sample O
Sample O
Page 28
RSU01 – Nov 2023