Declaration - COVID-19 Leave payment

By submitting this form, you (the employer or self-employed person) are declaring that you:

  • Meet the eligibility criteria for the payment:
    • The employees named in your application are legally employed in New Zealand, cannot undertake work and:
      • are self-isolating in accordance with public health guidance, have registered with Healthline and are not a person who is self isolating because they left New Zealand after the travel restrictions came into effect after 15 March 2020; or
      • are caring for dependents who are required to self-isolate or who are sick with COVID-19; or
      • are sick with COVID 19.
    • You agree you will promptly pass on as wages or salary, in full, the COVID-19 Leave Payment directly to employees named in your application
  • Will notify the Ministry of Social Development if anything changes that may affect your eligibility.
  • Have discussed this application with the employees named in your application and that they have consented (in writing, if practicable) to the information about them in the application:
    • Being provided to the Ministry of Social Development; and
    • Being used by the Ministry of Social Development to make decisions about your application and to audit and review any subsidy or payment that is granted; and
    • Being shared by the Ministry of Social Development with other agencies to the extent required by MSD, it's staff and auditors to make decisions about your application and to audit and review any payment that is granted.
  • Will provide the Ministry of Social Development with information about you, your business or (with their consent) your employees to the extent required by the Ministry of Social Development, it's staff or auditors to make decisions about your application and to audit and review any payment that is granted.
  • Consent to the Ministry of Social Development sharing information provided in this application about you or your business with other agencies to the extent necessary to make decisions about your application and to audit and review any payment that is granted.
  • Consent to the Ministry of Social Development publishing basic identifying information about your business and the level and duration of any payment provided to you (excluding any personal information about your employees) on a publicly accessible register
  • Acknowledge and agree all of the information you have provided to the Ministry of Social Development is true and correct
  • Agree to repay any payment made to you if you:
    • were not or stop being entitled to the payment
    • provide false or misleading information in your application;
    • receive business interruption insurance
  • Acknowledge if you have provided false or misleading information, or receive any payment that you were not entitled to receive, you may be subject to an investigation including for offences under the Crimes Act 1961.
  • Acknowledge that this declaration forms part of your application.
  • Acknowledge that the Ministry of Social Development may amend this agreement at any time and at their discretion.

In submitting your application you also acknowledge and/or agree:

  • The Ministry of Social Development collects the information in this application and form to determine whether you are eligible to receive assistance.
  • The Ministry of Social Development will use the information provided in this application to assess your eligibility to receive the COVID-19 Leave Payment. The Ministry of Social Development may also use the information to contact you or for research and reporting purposes, or to advise you on the matters relating to the assistance you applied for.
  • The Ministry will not use the information provided in this application for any other purpose or for assessing entitlement to any other assistance available from the Ministry unless required or authorised by law.
  • Under the Privacy Act 1993 you have the right to request access to all information held about yourself and to request corrections to that information.