RESET
Please send this completed form and
supporting documents to:
AMP KiwiSaver Scheme
Freepost 170, PO Box 55
Shortland Street, Auckland 1140
AMP KiwiSaver Scheme
Significant financial hardship application
Please call us on 0800 267 5494
if you have any queries.
Use this form to apply for an early withdrawal of some of your KiwiSaver savings if you’re experiencing, or likely to experience,
significant financial hardship.
KiwiSaver is specifically designed to help you save for your retirement. There are only very limited circumstances where you can withdraw your KiwiSaver
savings for other reasons. One of these reasons is significant financial hardship.
To make a significant financial hardship withdrawal, you’ll need to provide evidence that you’re suffering or likely to suffer significant financial
difficulties because you’re:
−− unable to meet your minimum living expenses
−− unable to meet the mortgage repayments on your home, resulting in your mortgage provider enforcing the mortgage on your property
−− modifying your home to meet special needs because you or a dependent family member has a disability
−− paying for medical treatment as a result of you or a dependent family member being ill or injured
−− paying for palliative care for you or a dependent family member
−− incurring funeral costs if a dependent family member dies
−− suffering from serious illness^
If you don’t meet the above criteria, but are finding it hard to continue with your KiwiSaver contributions, remember that you can apply for a
contributions holiday – please visit www.kiwisaver.govt.nz for more information.
You can’t use a significant financial hardship withdrawal to cover fines, Inland Revenue, WINZ or debit collection agency payments. Regular
payment plans can usually be arranged with those agencies.
We can’t process your withdrawal if you haven’t provided verification of your identity, so please make sure you complete sections (g) and (h).
If you have applied for a significant financial hardship withdrawal from the AMP KiwiSaver Scheme before, the Supervisor will ask you to get
advice from a budget adviser before they assess this new withdrawal request. You will also have to provide updated evidence to support your
application (see section (f) of this form).
^ A serious illness means an injury, illness or disability that results in you being totally and permanently unable to engage in work for which you are suited by reason of
experience, education, or training, or any combination of these things or an injury, illness or disability that poses a serious and imminent risk of death. If you are applying
for a significant financial hardship withdrawal request on grounds of serious illness please complete a “Serious Illness Application” Form.
This form can be completed on-screen by typing content directly into the PDF document. Please use block letters if you’re not completing this
form online.
Once you have completed and signed this form please send it and any supporting documents to the address above.
A disclosure statement is available from your Adviser, on request and free of charge.
*These fields must be completed
(a) Your personal details
*Member number
K
*Date of birth
Title:
Mr
Mrs
Ms
Miss
Dr
D D M M Y
Other
*First names
*Surname
*IRD number
*Email
Y
Y
Y
*Residential address
Postcode
*Postal address
Postcode
*Please provide at least one contact number
Home phone
(
Work phone
)
PIE tax rate
(
10.5%
17.5%
28%
)
Mobile phone
(
)
We deduct PIE tax from your withdrawal using the information we have at the time your
withdrawal is paid. If you’re unsure of your PIE tax rate, please go to www.amp.co.nz/PIE for help
or contact your Adviser or Inland Revenue.
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(b) Withdrawal details
*I request (please tick):
or
the full value of my AMP KiwiSaver Scheme account less the $1,000 Government kick-start (if you have received one), member tax credits and
any fees, expense and taxes.
a partial withdrawal of $ _ ________________________ If you’ve requested a partial withdrawal above, and you’re invested in more than one investment fund, please tell us below which funds to withdraw
from. If you don’t tell us the funds and amounts, we’ll split the withdrawal equally across your funds.
Investment fund(s)
Amount ($)
Investment fund(s)
Amount ($)
Please note: the Supervisor may grant only part of the withdrawal you’ve applied for.
(c) Payment instructions
Please provide your proof of bank account in the form of an original pre-encoded bank deposit slip or a certified true copy of a bank statement.
The bank account must be a New Zealand bank account in your name or be a joint account incorporating your name.
*Account name
*Account number
-
-
-
*I have attached evidence of my bank account (e.g. a pre-encoded bank deposit slip, bank statement). Note: No cheque payments are available.
(d) Statement of Financial Position (please provide recent information, i.e. no older than two weeks prior to the date statement is completed and signed)
Note: You must complete this section. Information must include all of your household, business and personal assets and liabilities including
your spouse/partner where sought below. If you require more space please attach a list (including all relevant information as set out above) to
this application. If you have any questions when completing this form, please contact your Adviser or call Customer Services on 0800 267 5494.
Number of Dependants
Age of Dependants
Please provide Birth certificates for all dependants under 18 years.
Are you employed?
If yes, is it:
Are you:
Yes
No
Full time
Part time
Single
Casual
Married/De Facto Relationship
Spouse/partner first name
Is your partner employed? Yes
If yes, is it:
Full time
Spouse/partner last name
No
Part time
Casual
Assets you own
Property owned
Valuation date
Values
D D M M Y
Y
Y
Y
$
D D M M Y
Y
Y
Y
$
Accounts - list all bank accounts (attach certified copies of your bank statements for the last three months)
Bank and branch
Account number
Balance
$
$
$
Other accounts - list all other accounts, e.g. credit union, building society (attach certified copies of your statements for the last three months)
Account type
Balance
$
$
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Other assets
Asset type
Value
Shares
$
Debentures
$
Other (e.g. Bonus bonds, loans, money owed to you)
$
Superannuation policies (current value)
$
$
Vehicles (e.g. car, boat, caravan – list the make, model and year)
$
$
Other - (specify):
$
$
Total all assets (add all amounts in the right hand column) and insert total in box (1)
(1) $
Liabilities/debts you owe – complete all details and attach certified copies of accounts for the last three months
Mortgages/loans/bank overdrafts – list bank or institution
Credit limit
Amount owing
Amount overdue
$
$
$
$
$
$
$
$
$
Total balance overdue amounts (add all amounts in the right hand column) and insert total in box (i)
$
(i) $
Credit/Store cards – list bank or institution
Credit limit
Amount owing
Amount overdue
$
$
$
$
$
$
$
$
$
Total balance overdue amounts (add all amounts in the right hand column) and insert total in box (ii)
$
(ii) $
Other debts/Hire purchase – e.g any rent arrears
Credit limit
Amount owing
Amount overdue
$
$
$
$
$
$
$
$
$
$
(iii) $
Total balance overdue amounts (add all amounts in the right hand column) and insert total in box (iii)
Total all liabilities (add all amounts in the right hand column) and insert total in box (2)
(2) $
Income and expenses - Information must include the total household income and expenditure
Note: Monthly to weekly = x 12 ÷ 52
Annual to weekly = ÷52
Income (weekly, net after tax)
enter all sources of income, including details of your spouse or partner’s
income
Weekly amount
Salary/wages/part-time work (provide last four payslips)
$
Spouse or partner’s income (provide last four payslips)
$
Self-employed income
$
Working for Families Tax Credits
$
WINZ benefit/Superannuation
$
Child support received
$
Rent/board received
$
Other (specify):
$
$
$
Total all income (add all amounts in the right hand column and insert total in box (3))
(3) $
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Expenses (weekly)
enter all weekly expenses, including details of your spouse or partner’s expenses
(attach certified copies of payment demands for accounts that are in arrears)
Weekly amount
Food/groceries
$
Rent/board/mortgage
$
Bus/train/petrol
$
Childcare/school expenses
$
Child maintenance payments
$
Gas/electricity
$
Telephone/mobile
$
Clothing
$
Hire purchase payments
$
Credit/Store card(s) payments
$
Loan repayments
$
Insurance (car, house, contents, boat etc)
$
Vehicle registration(s)
$
Council rates
$
Water rates (if applicable)
$
Medical insurance
$
Life insurance/superannuation
$
Other (specify)
$
$
$
Total all expenses (add all amounts in the right hand column and insert total in box (4))
Surplus/Deficit
(4) $
(3) - (4) = $
If you have a surplus you may not qualify for a Significant Financial Hardship withdrawal.
Please describe below what efforts you have made to obtain finance elsewhere including details of lenders you have approached.
Please outline your financial position and the reason you are applying for a financial hardship withdrawal.
Have you made a claim for Significant Financial Hardship from a KiwiSaver scheme provider in the last 12 months?
Yes
No
If ‘Yes’ was the claim paid?
Yes
No
Yes
No
If you have answered ‘Yes’ please attach confirmation that you have obtained advice from a budget Adviser.
Have you been declared bankrupt?
If you have answered 'Yes', please contact us on 0800 267 5494.
Where can I get budgeting advice?
For free, confidential budget advice you can visit the website www.sorted.org.nz or call the New Zealand Federation of Family Budgeting Services on
0508 283 438.
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(e) Statutory declaration
*I (full name of member)
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K
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*of (Address)
B
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K
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T
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S
B
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K
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E
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Occupation
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solemnly and sincerely declare that:
1. I am a member of the AMP KiwiSaver Scheme;
2. I am applying to the Supervisor for a withdrawal from my AMP KiwiSaver Scheme Account as detailed in this application;
3. I am experiencing or likely to experience significant financial hardship as defined in the KiwiSaver Act 2006 for the following reason(s), (please tick)
unable to meet my minimum living expenses
unable to meet the mortgage repayments on my home, resulting in my mortgage provider enforcing the mortgage on my property
modifying my home to meet special needs because I or a dependent family member has a disability
paying for medical treatment as a result of me or a dependent family member being ill or injured
paying for palliative care for me or a dependent family member
incurring funeral costs if a dependent family member dies
4. I confirm that I have explored and exhausted all reasonable alternatives of funding to relieve my significant financial hardship including
borrowing money;
5. The information provided in this application, including the Statement of Financial Position and any attachments, is complete and true and correct.
6. I understand that acceptance of the application is at the discretion of the Supervisor and that fees may apply;
7. I understand that AMP and/or the Supervisor may request additional information from me relating to this application;
8. I am aware that if the Supervisor accepts my application, the Supervisor may limit the amount that I am able to withdraw to an amount that in its
opinion is required to alleviate my financial hardship;
9. I acknowledge that the Privacy Act 1993 provides me with the right to request access to and/or correction of any of my personal information held
by AMP (AMP in this context includes all the members of the AMP Group of Companies and their subsidiaries, associated companies and agents)
or the Supervisor of the AMP KiwiSaver Scheme. I understand that the information supplied by me with this application will be used to process
this Application and to administer my membership of the AMP KiwiSaver Scheme (and may be disclosed for these purposes to third parties where
relevant, including the Inland Revenue, my Adviser, my employer’s Adviser, or another intermediary or distributor). I authorise AMP and/or the
Supervisor to obtain additional information in relation to this application from any third party/entity.
10. I confirm that I am not an undischarged bankrupt or incapable of managing my financial affairs and that I am properly entitled to any payment made
pursuant to this application and that no other person has any claim against it.
11. I indemnify the Supervisor, AMP and any of their related companies against all claims, actions, demands, proceedings, costs or expenses, damages or
liability arising and discharge them from any liability in respect of my membership of the AMP KiwiSaver Scheme and/or any withdrawal payment made.
And I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957.
*Declared at PLACE
D D M M Y
*This (date)
Y
Y
Y
SIGN HERE
*Member’s signature
before me (Justice of the Peace, solicitor, notary public, or other person authorised to take statutory declaration, such as the Registrar or Deputy Registrar
of the High Court or of any District Court or a member of Parliament):
*Full name, title/office of person taking declaration
*of city (where signing)
*Occupation
*Signature of person authorised to take declaration
*Date
SIGN HERE
D D M M Y
Y
Y
Y
Please also complete section (h) (if required).
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(f) Supporting documentation
Please note: the Supervisor may grant only part of the withdrawal you’ve applied for.
Please ensure requested information is provided and attach copies as requested. You may also wish to attach additional information which supports
your financial position. We may also request more information about your financial position. Note: If all requested information is not provided your
application will be declined.
The Supervisor and/or Manager may also request further financial information from you.
Please tick below the supporting documentation you’re supplying with this application:
If this is not your first withdrawal, please provide report from Budget Advisory Services (e.g. Citizens Advice Bureau or New Zealand Federation of
Family Budgeting Services) or an accountant’s report explaining your financial position (the report should include your income, expenses and if
there is a loss or a surplus).
Proof of debts that are in arrears - this must be notices of outstanding debt that are in arrears, recent demands from your bank or other debtors,
credit card accounts, including transactions. This must not be older than 30 days from the date you apply for the withdrawal.
Certified copies of all bank accounts and other account statements for both you and your spouse for the last three months from the date you apply
for withdrawal.
Certified copies of all debt account statements (such as mortgages, loans, overdrafts and credit cards etc) for both you and your spouse for the last
three months. This must not be older than 30 days from the date you apply for withdrawal.
A copy of your contributions holiday approval notice from Inland Revenue (if applicable).
A copy of your WINZ entitlement letter with a breakdown of your benefit and any commitments that WINZ is paying on your behalf and if you have
a stand down period (if applicable)
Have you received financial advice from an Adviser in making this decision to apply for a withdrawal?
Yes
No
If yes, please ensure your Adviser completes the Adviser section at the end of this form.
(g) Provide your identification to verify your identity and address
Please complete option 1 in the table below and attach copies of the requested document (please tick which document you are providing). If you cannot
provide a document from option 1, then complete option 2 or 3.
If you are under 18 years of age, your parent/s or guardian should complete a separate ‘Acting on behalf of’ identity verification form. This form can be found on
amp.co.nz within the documents and downloads section, or you can request a copy of this form by emailing kiwisaver@amp.co.nz or calling 0800 267 5494.
Option 1: ONE document from this section
NZ passport (Identity page)
NZ firearms licence
Overseas passport (Identity page)
NZ certificate of Identity
Option 2: NZ Driver’s Licence PLUS (ONE of the documents from this section)
Super Gold card
NZ full birth certificate/birth certificate issued
by foreign government
NZ citizenship certificate/citizenship certificate issued by
foreign government
Bank statement or Inland Revenue statement issued in your
name in the last 6 months
Option 3: 18+ identity card PLUS (ONE of the documents from this section)
NZ full birth certificate/birth certificate issued by foreign
government
NZ citizenship certificate/citizenship certificate issued by
foreign government
IMPORTANT: If you are providing previously certified identity documents, please ensure the documents have been certified not more than 3 months prior.
Please attach only the certified photocopies of the original documents to this application.
Proof of address
As well as providing your identity documents you must also supply proof of your address. Tick one document option from this section.
The document you supply needs to be addressed to you at the residential address detailed in section (a) and dated within the last 6 months.
Letter or invoice from utility company
Bank statement
Letter from government agency (e.g. Inland Revenue, rates bill)
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(h) Certify or verify your identity and address documents
Your identity and address documents can be:
−− Certified by a trusted referee (use the first box below), or verified by an Adviser/AMP employee acting as agent of AMP (use the second box below)
−−
DECLARATION BY TRUSTED REFEREE
I,
FULL NAME OF TRUSTED REFEREE/AMP EMPLOYEE
confirm that
1. I have sighted today the original of each document identified with a tick in section (g) above verifying the identity and address of the person
named in section (a) of this form, and attached to this statement are true copies of those documents initialled and dated by me.
2. The documents that have been provided represent the identity of the person named in section (a) of this form.
3. I am a (tick one of the following)
New Zealand Lawyer
Justice of the Peace
Notary Public
Registered Medical Doctor
Chartered Accountant
Police Constable
Registered Teacher
Kaumãtua
Member of Parliament
Minister of Religion
Commonwealth Representative
NZ Honorary Consul
4. I am not related to and do not live at the same address as the person named in section (a) of this form.
Signature of trusted referee
Dated
D D M M Y
SIGN HERE
Y
Y
Y
OR
DECLARATION BY ADVISER/AMP EMPLOYEE (AS AGENT OF AMP)
I,
FULL NAME OF ADVISER/AMP EMPLOYEE
ADVISER CODE (if applicable)
confirm that
1. I have sighted today the original of each document identified with a tick in section (g) above verifying the identity and address of the person
named in section (a) of this form, and attached to this statement, are true copies of those documents initialled and dated by me.
2. I have no reason to believe that this person is not who he/she claims to be.
3. AMP has authorised me to be its agent to conduct customer due diligence procedures and obtain any information required for customer due
diligence under the Anti-Money Laundering and Countering Financing of Terrorism Act 2009 and I acknowledge that AMP is relying on me to
perform those functions for it.
Signature of Agent of AMP
Dated
SIGN HERE
D D M M Y
Y
Y
Y
(i) *Checklist and next steps
*Checklist
Please check you have completed the form correctly
Have you completed all fields with an *?
Have you completed the Statement of Financial Position (section (d))?
Have you completed the statutory declaration in section (e)?
Have you attached any necessary verification of identity and proof of
address documents?
Have you attached proof of your bank account in the form of an
original pre-encoded bank deposit slip or a certified true copy of a
bank statement?
If you are under 18 years of age, has your parent/s or guardian
completed a separate `Acting on behalf of’ identity verification form
and attached documents required by that form?
Next steps:
-If the Supervisor approves your request we’ll direct credit your account with the amount approved and send you confirmation of the payment made.
- If your request is not approved we will advise you.
-It’s important that ALL supporting documentation is provided with this application. Failing to do so will delay the application process or result in
your application being declined.
The Supervisor and/or the Manager may also request further financial information from you.
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( j) For Adviser use only
AMP Adviser name (if applicable)
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AMP Adviser number
E
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FSPN (please use your QFE’s FSPN if you are a QFE Adviser)
I confirm that I am a:
AFA (entitled to sell Category 1 Product)
AMP QFE Category 1 Adviser
Other
And I certify that the information provided in this Adviser use only section is correct and that I have complied with the requirements of the
Financial Advisers Act 2008 and all other applicable laws.
Signature of Adviser
Date
SIGN HERE
D D M M Y
Y
Y
Y
WEL539120 (05/16)
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