Unsupported Child’s Benefit
interview form
This interview form needs to be completed with all Unsupported Child’s Benefit applications. It helps to find out:
• if a breakdown in the child’s family has taken place
• whether the parents are able but unwilling to provide full support for the child
• why (due to the breakdown) the child’s natural, adoptive or step-parent is unable to provide fully for the child
• the period the parent(s) are unable to provide fully for the child
• how long the caregiver is likely to have the child in their care
• what the caregiver’s responsibilities are.
Please try to write as much of the applicant’s or young person’s own words as possible.
Applicant’s
1
What is the applicant’s client number?
details
2
What is the applicant’s full name?
First and middle names
Surname or family name
3
What date was the applicant born?
Day
Month
Year
Child/Young 4
What is the child/young person’s full name?
person’s
First and middle names
Surname or family name
details
5
What is their date of birth?
Day
Month
Year
Family
6
Why can’t the child/young person live with their mother?
Breakdown
Please explain what’s happened
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INFORMATION FOR Q7:
7
When did the breakdown with the mother occur?
This will help us
understand the
timeframe for the family
breakdown.
Day
Month
Year
Uncertain of the date
Tell us how long the situation has been going on
INFORMATION FOR Q8:
8
What steps (if any) have been taken to reconcile the breakdown with their
This will help us
mother?
understand if the
situation could be short
term or a longer duration.
9
Why can’t the child/young person live with their father?
Please explain what’s happened.
INFORMATION FOR Q10:
10
When did the breakdown with the father occur?
This will help us
understand the
timeframe for the family
breakdown.
Day
Month
Year
Uncertain of the date
Tell us how long the situation has been going on
INFORMATION FOR Q11:
11
What steps (if any) have been taken to reconcile the breakdown with their
This will help us
father?
understand if the
situation could be short
term or a longer duration.
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V12W – JUN 2020
Financial
12
What financial support for the child was arranged when the care decision was
support
made?
13
Why can’t the mother financially support the child?
14
Why can’t the father financially support the child?
Living with
15
Is the living arrangement likely to change?
the caregiver
No
INFORMATION FOR Q15:
This will help determine
Yes
Tell us what would need to happen to bring about a change, and when it
would be likely to happen?
if the arrangement will be
short or long term
16
How does the applicant describe the living arrangement?
Boarding
Renting
Caregiving
Uncertain
Please describe the arrangement below
17
When did the arrangement become permanent?
Please provide more information below
Day
Month
Year
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Other
18
Are there any other agencies supporting the child/young person, parents or
support
caregiver?
No
Yes
Tell us which agencies are providing support
19
Has the applicant applied for Child Support?
No
Yes
Please ask the applicant to complete a Child Support application form as they’re
required by the Child Support legislation to apply for this.
20
Please provide any other information that may be helpful.
Declaration
The information I have given in this interview that has been documented above is true and complete.
I understand that the Ministry of Social Development may share information with an assessment provider to
help to determine my eligibility for this assistance.
Young person’s name (print)
Young person’s signature (if aged 14 years or over) Date
Day
Month
Year
Applicant’s name (print)
Applicant’s signature
Date
Day
Month
Year
Interviewer’s name (print)
Interviewer’s signature
Date
Day
Month
Year
Page 4
V12W – JUN 2020
