Childcare Assistance – Change of Circumstances - Work and Income [PDF]

Aug 24, 2012 - Childcare Assistance – Change of Circumstances. CLIENT NUMBER. Please read this before you start. What

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Idea Transcript


Childcare Assistance – Change of Circumstances

CLIENT NUMBER

Please read this before you start

Please use a separate form for each child. The childcare centre/programme needs to verify the changes by signing the form. If you/your partner are training, your Training Provider also needs to sign the form. Please complete all questions – if not applicable write N/A.

What to bring 3

When you complete and return this form you will need to provide the following: identification for you and your partner (if you have one)

If you are receiving Childcare Assistance, you must tell us straight away about any changes which could affect your payment. Your partner has the same responsibility.

Client details

your child’s full birth certificate for any child added proof of your and/or your partner’s income if it has changed details of your work, course, organised activity, you and/or your child(ren)’s medical details (if applicable).

1.

What is your name? First name(s)

Surname or family name

Q2 note: Please give your house number, street, suburb, and town or city.

2.

Where do you live? Flat/house no.

A house number could include: • street number

Street name

Suburb

City

• fire • RAPID • emergency services.

Birth date

3.

What is your date of birth?



Child’s details

4.

Day

Month

Year

What is the child’s name? First name(s)

Please use a separate form for each child attending the childcare centre/ programme.

Surname or family name

5.

What is the child’s date of birth?



Day

R24 – AUG 2012

Month

Year

1

Childcare changes

6.

Only complete the question(s) that affect you.

The number of hours of childcare has changed:

No u Go to Question 7



Yes u Please provide details below:

New hours per week

Start date



Day

Month

Year

New fee change per week $ Reason for change:

7.

The fee to the childcare centre/programme has changed:

No u Go to Question 8



Yes u Please provide details below:

New fee change per week

Start date

$

8.

Day

Month

Year

The child has moved to a new childcare centre/programme:

No u Go to Question 9



Yes u Please provide details below:

Name of old childcare centre/programme

End date



Day

Month

Name of new childcare centre/programme

Hours of care per week

Start date



Day

Month

Year

New fee change per week $

9.

Please complete the following if this child receives 20 Hours ECE: Hours of 20 Hour ECE received (weekly total)



Supervisor to sign This information is required under section 12 of the Social Security Act 1964.

Date 20 Hour ECE started

Day

Month

Year

The information provided in Questions 6–9 is true and complete. Work and Income childcare service number:

Supervisor’s name (print)

Supervisor’s signature

2

Day R24 – AUG 2012

Month

Year

Year

Client details

10.

Please tick which box applies to you.

Have your training or study details changed?

No u Go to Question 11



Yes u Please provide details below:

I stopped attending a work related course or study on:



Day

Month

Year

OR I am on a work related course or study. Provider’s name



Name of course

Is the course NZQA accredited?

No



Yes u

Course start date





Day

Month

Course end date

Year

Day

Month

Hours spent: At your course

Partner details

Please provide details below:

Travelling from the centre to your course and returning

On other study



Please ensure your Training Provider signs the statement below.

11.

Have your partner’s training or study details changed?

Please tick which box applies to you.



No



Yes u Please provide details below:

Year

My partner stopped attending a work related course or study on:



Day

Month

Year

OR My partner is on a work related course or study. Provider’s name



Name of course

Is the course NZQA accredited?

No



Yes u





Course start date

Day

Trainer statement Please get your training organisation to complete this section.

Month

Course end date

Year

Day

Hours spent: At your course



Please provide details below:

Month

Year

Travelling from the centre to your course and returning

On other study

Please ensure your Training Provider signs the statement below.

I confirm that the above details are true and complete. Trainer’s name (print)

Trainer’s signature Official Training Provider’s Stamp



Day R24 – AUG 2012

Month

Year 3

12.

Have your hours of work and travel time changed?

No u Go to Question 13



Yes u Hours of work per week (including lunch breaks):

Q13 note: Examples of income from other sources: • wages or salary

13.

• accident compensation • farm or business income (include drawings) • self employment



u Hours travelling from centre to work and returning:

Has your gross family income changed?

No u Please sign the client statement below:



Yes u Please provide details below:

My gross family income has changed from:

• interest from savings or investments



• dividends from shares

Income source (List jobs and other sources of income)

• income from rents • redundancy or termination type payments

Day

Month

Year

Your gross income a week BEFORE TAX

Your partner’s gross income a week BEFORE TAX



$

$



$

$

• maintenance payments



$

$

• boarders



$

$



$

$



$

$



$

$



$

$



$

$ $

• Child Support

• Student Allowance or scholarship • any other income, eg family trusts, overseas payments. Give gross (before tax) amount. Please attach proof of your income.



Client statement



TOTAL

$



TOTAL COMBINED INCOME

$

If you are self-employed, please provide your full set of business accounts for the last 12 months. If your income changed over the year, please provide your income details for the last 26 weeks.

I have completed all questions on this Childcare Assistance – Change of Circumstances form, or it has been completed for me, and the information I have given is true and complete.

Client’s name (print)

Client’s signature



Day

Month

Year

OFFICE USE ONLY SWIFTT ACTION • CCSI/CCSC Screens • CDTSA-enter holiday dates and/or next term school dates • Care periods must be entered • Check RNCLI Screen for CDA.

Comments:

Processor’s signature 10%

100%

Critical data

Month

Year

Day

Month

Year

Checker’s signature

4

Day

R24 – AUG 2012

Printed in New Zealand on paper sourced from well-managed sustainable forests using mineral oil free, soy-based vegetable inks

Income details

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