AMP KiwiSaver Scheme Significant financial hardship application *These fields must be completed
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Please send this completed form and
supporting documents to:
AMP KiwiSaver Scheme
AMP KiwiSaver Scheme Freepost 170, PO Box 55
Shortland Street, Auckland 1140
Significant financial hardship application Fax to 0800 509 955 or
Email kiwisaver@amp.co.nz
*These fields must be completed
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 Trustee 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 you’ll need to provide a declaration of serious illness from your doctor.
This form can be completed on-screen by typing content directly into the PDF document. Once you have completed your details, print, sign and
send the form and any supporting documents to the address above.
If you have any questions when completing this form, please contact your Adviser or call Customer Services on 0800 267 5494. A disclosure
statement is available from your Adviser on request and free of charge.
(a) Your personal details
*Member number:
K
Email:
Title:
Mr Mrs Ms Miss Dr Other
*First names: *Surname:
*IRD number: *Occupation:
*Postal address:
Postcode:
Home phone: Work phone: Mobile phone:
( ) ( ) ( )
PIE tax rate: 10.5% 17.5% 28%
We deduct PIE tax from your withdrawal using the information we have at the time you withdraw – if your PIE tax details have changed, please tell us your new
PIE tax rate. If you’re unsure of your PIE tax rate, please go to amp.co.nz/PIE for help or contact your Adviser or Inland Revenue.
1 of 7(b) Statutory declaration
I (full name of member)
B L O C K L E T T E R S
*of (Address)
B L O C K L E T T E R S
B L O C K L E T T E R S
Occupation
B L O C K L E T T E R S
solemnly and sincerely declare that:
1. I am a member of the AMP KiwiSaver Scheme;
2. I am applying to the Trustee 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
suffering serious illness
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 in this application (and any attachments to this application – including the Statement of Financial Position) is complete and true
and correct.
6. I understand that acceptance of the application is at the discretion of the Trustee and that fees may apply;
7. I understand that AMP and/or the Trustee may request additional information from me relating to this application;
8. I am aware that if the Trustee accepts my application, the Trustee 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
Trustee 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 Trustee 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 Trustee, 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 *This (date) D D M M Y Y Y Y
*Member’s signature SIGN HERE
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
D D M M Y Y Y Y
SIGN HERE
(c) Withdrawal details
*I request (please tick):
the full value of my AMP KiwiSaver Scheme account less the $1,000 Government kick-start, member tax credits and any fees, expense and taxes.
or
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 ($)
2 of 7(d) Payment instructions
*Account name (account held in my name or jointly held in my name):
*Account number:
*I have attached evidence of my bank account (e.g. a pre-printed bank deposit slip, bank statement). Note: No cheque payments are available.
(e) 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.
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
$
$
Other assets
Asset type Value
Shares $
Debentures $
Other (e.g. Bonus bonds, loans, money owed to you) $
Household goods $
Life insurance/superannuation policies (surrender or current value) $
Vehicles (e.g. car, boat, caravan – list the make including model, year and registration number) $
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 Balance to pay Balance overdue
$ $ $
$ $ $
$ $ $
Total balance overdue amounts (add all amounts in the right hand column) and insert total in box (i) $ (i) $
Credit cards – list bank or institution Credit limit Balance to pay Balance overdue
$ $ $
$ $ $
$ $ $
Total balance overdue amounts (add all amounts in the right hand column) and insert total in box (ii) $ (ii) $
3 of 7Other debts / Hire purchase – list bank or institution Credit limit Balance to pay Balance overdue
$ $ $
$ $ $
$ $ $
Total balance overdue amounts (add all amounts in the right hand column) and insert total in box (iii) $ (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 Weekly amount
income
Salary/wages/part-time work (include any pension payments) $
Spouse or partner’s income $
Self-employed income $
Child support received $
Rent/board received $
Interest/dividends $
Other (specify): $
$
$
Total all income (add all amounts in the right hand column and insert total in box (3)) (3) $
Expenses (weekly)
enter all weekly expenses, including details of your spouse or partner’s expenses Weekly amount
(attach certified copies of payment demands for accounts that are in arrears)
Food/groceries $
Rent/board/mortgage $
Bus/train/petrol $
Childcare/school expenses $
Child maintenance payments $
Gas/electricity $
Telephone/mobile $
Clothing $
Hire purchase payments $
Credit card(s) payments $
Loan repayments $
Insurance (car, house, contents, boat etc) $
Vehicle registration(s) $
Rates $
Medical insurance $
Life insurance/superannuation $
Other (specify): $
$
$
Total all expenses (add all amounts in the right hand column and insert total in box (4)) (4) $
Surplus/Deficit (3) - (4) = $
4 of 7Please describe below what efforts you have made to obtain finance elsewhere including details of lenders you have approached.
Please describe below how your circumstances have changed since you joined the AMP KiwiSaver Scheme and the reason you are requesting a significant
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
If you have answered ‘Yes’ please attach confirmation that you have obtained advice from a budget Adviser.
Have you been declared bankrupt? Yes No
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.
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.
(f) Supporting documentation
Please note: the Trustee may grant only part of the withdrawal you’ve applied for.
It is important that ALL supporting documentation is provided with this application form. Failing to do so will delay the application process or result in
your application being declined.
The Trustee and/or Manager may also request further financial information from you.
Please tick below the supporting documentation you’re supplying with this application:
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.
Certified copies of all bank accounts and other account statements for both you and your spouse for the last three months.
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.
A copy of your contributions holiday approval notice from Inland Revenue (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.
5 of 7(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 Product Information and Forms 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
Current NZ passport (Identity page) Current NZ firearms licence
Current overseas passport (Identity page) Current NZ certificate of Identity
Option 2: Current NZ Driver Licence PLUS (ONE of the of the documents from this section)
Super Gold card Full birth certificate
Credit card/debit card/eftpos card from a NZ registered bank Bank statement or IRD statement issued in your name in the last
(containing name and legible signature) 12 months
NZ citizenship certificate/citizenship certificate issued by
Community Services card
foreign government
Option 3: Current 18+ identity card PLUS (ONE of the documents from this section)
NZ full birth certificate/Birth certificate issued by foreign NZ citizenship certificate/citizenship certificate issued by
government 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 12 months.
Letter or invoice from utility company Bank statement Letter from government agency (e.g. Inland Revenue, rates bill)
(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 acting as agent of AMP (use the second box below)
−−
DECLARATION BY TRUSTED REFEREE
FULL NAME OF TRUSTED REFEREE
I, confirm that
1. I have sighted today the original of each document identified with a tick in section (e) 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 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 Kaumatua
Member of Parliament Minister of religion
4. I am not related to and do not live at the same address as the person named in section (a) of this form, and I am over 16 years of age.
Signature of trusted referee Dated
D D M M Y Y Y Y
SIGN HERE
OR
DECLARATION BY ADVISER (AS AGENT OF AMP)
FULL NAME OF ADVISER
I, ADVISER CODE confirm that
1. I have sighted today the original of each document identified with a tick in section (e) 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 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 Adviser Dated
D D M M Y Y Y Y
SIGN HERE
6 of 7(i) For Adviser use only
AMP Adviser name (if applicable) AMP Adviser number
B L O C K L E T T E R S
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 Information 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:
D D M M Y Y Y Y
SIGN HERE
Next steps:
- If the Trustee 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 Trustee and/or AMP may also request further financial information from you.
*Checklist:
Please check you have completed the form correctly If you have not previously sent AMP verified identity documents,
Have you completed all fields with an *? have you attached copies of your identity documents that have been
certified by your trusted referee or verified by your Adviser? Has the
Have you completed the statutory declaration in section (d)?
declaration in section (h) been completed?
Have you included a deposit slip with your bank account details (this
Have you provided a copy of your proof of address dated within the
should be pre-printed or bank stamped)?
last 12 months?
Have you completed the Statement of Financial Position (section (e))?
If you are under 18 years of age, has your parent/s or guardian
Have you supplied all documents to support your application completed a separate `Acting on behalf of’ identity verification form
(including those in section (f)? and attached documents required by that form?
WEL360493 (09/13)
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