Forms for providers

A

• Activity in the Community Sponsor Application [PDF 489 KB]

  EMPL1001W - Apr 2016

• Appointment of an Agent [PDF 951 KB]

  V01 - JUL 2024

B

• Brochures

  Providers can check if they've got the latest version of a Work and Income brochure or order some more.

C

• Child Disability Allowance - Medical Certificate [PDF 198 KB]

  V12CW - JAN 2020

• Childcare / OSCAR provider Registration form [PDF 101 KB]

  S62W - OCT 2016

• Childcare and OSCAR subsidy application form [PDF 1.3 MB]

  S02 - DEC 2024

• Childcare Assistance - Change of Circumstances [PDF 825 KB]

  R24 - MAR 2025

D

• Dental treatment information [PDF 157 KB]

  V15 – NOV 2022

  This form should be completed by a dentist, for a person who needs help to pay for an oral health issue that already has or would immediately begin to deteriorate if left untreated, and already is or is likely to have a detrimental effect on the person's oral and/or physical health.

• Designated Doctor Application [PDF 109 KB]

  HDS009W - JUL 2013

  If you are interested in becoming a Work and Income designated doctor, please complete this form and return it to Work and Income's Health and Disability Team in your area.

• Disability Allowance - Medical Alarm Assessment Form [PDF 177 KB]

  S21 - DEC 2022

• Disability Allowance medical certificate [PDF 197 KB]

  S22 - APR 2020

  Registered medical or nurse practitioner to complete

• Disability Certificate - Counselling [PDF 665 KB]

  S23 - NOV 2024

  Counsellor and registered medical or nurse practitioner to complete

• Drug testing registration of interest form [PDF 92 KB]

  LAB402W - OCT 2013

  This registration form sets out the information required from drug testing agencies who wish to register their interest in becoming a potential provider of drug tests for Work and Income beneficiaries who are required to pass a drug test.

E

• Early Learning Payment application form [PDF 1006 KB]

  S32W - JUL 2023

• Emergency housing supplier standards opt in form [PDF 658 KB]

  SHA333W – Dec 2023

  If you’re an emergency housing supplier and want to opt-in to the Supplier Standards, you’ll need to complete this form.

G

• Guaranteed Childcare Assistance Payment Application [PDF 1.1 MB]

  YS008W - JUN 2024

  If you’re under 20 and in full-time education, training or work-based learning, you may be able to get Guaranteed Childcare Assistance Payment (GCAP) to help with the cost of pre-school childcare.

H

• Housing Modification Grant Income and Asset Details [PDF 115 KB]

  M27W - AUG 2009

L

• Limited Service Volunteer Medical Certificate [PDF 685 KB]

  LSV0002MCW - DEC 2023

M

• Medical Appeals Board hearing application [PDF 588 KB]

  HDS021W - AUG 2013

O

• Online payment schedule email request form [PDF 652 KB]

  S60W - JUN 2026

  If you are a childcare centre or OSCAR provider, you can use this form to add, change or cancel your email address for receiving payment schedules each week.

• OSCAR Funding application - Part one - Provider information [PDF 191 KB]

  S35W - JAN 2025

  If you (or your organisation) provide Out of School Care and Recreation (OSCAR) for 5 to 13 year olds before school, after school or as holiday programmes, you may be eligible for OSCAR grant funding from the Ministry of Social Development.

• OSCAR Funding application - Part two - Programme information [PDF 209 KB]

  S36W - JAN 2025

  If you (or your organisation) provide Out of School Care and Recreation (OSCAR) for 5 to 13 year olds before school, after school or as holiday programmes, you may be eligible for OSCAR grant funding from the Ministry of Social Development.

• OSCAR Subsidy Declaration [PDF 139 KB]

  R18 - DEC 2011

  The OSCAR Programme Supervisor will need to fill in part of this form.

• OSCAR Subsidy Verification Form [PDF 124 KB]

  S34W - DEC 2011

  This form needs to be completed by the OSCAR programme supervisor. The information you provide will help us to assess if the applicant is eligible for the OSCAR Subsidy.

P

• Pre-employment drug test claim form for drug testing agencies [PDF 661 KB]

  LAB400W - MAY 2024

  This form collects information required by Work and Income so a drug testing agency can claim back the cost of a drug test taken by a Work and Income client.

R

• Redirection of Benefit Payment [PDF 793 KB]

  V19 - JUL 2023

  A redirection of benefit payment is where part or all of your benefit is paid to another person or organisation by us. Requests for a redirection will only be approved in special circumstances and for good reason.

• Residential Care - Deferred Loan Application [PDF 978 KB]

  RSU09W - JUL 2023

  When a residential care loan becomes repayable, a deferred loan can be offered to people in certain circumstances.

• Residential Care notification form

  Residential care providers should complete this form when one of our clients is in long-term care and there's been a change in their situation.

• Residential Support Subsidy - Authorisation Form [PDF 662 KB]

  RSU08W - SEP 2020

  Residential Support Subsidy is a payment that helps with the cost of residential support for a person with a physical, sensory, intellectual, psychiatric disability (including drug and alcohol rehabilitation) or disabling chronic health condition who needs residential care as a result.

• Residential Support Subsidy Residents Details Notification Form [PDF 1.4 MB]

  RSU12W - JAN 2024

• Retailer, supplier, payee - change of details [PDF 727 KB]

  ISS26W - MAY 2025

  If you receive money from the Ministry of Social Development that relates to a client and you need to update your details with us, you’ll need to complete this form.

• Review of Decision Application [PDF 677 KB]

  R10 – Feb 2025

  If we've made a decision you don't agree with you can use this form to ask for a formal Review of Decision.

• Rural Assistance Payment Application [PDF 855 KB]

  RUR01W - MAY 2024

  The Rural Assistance Payment is a Special Needs Grant for farmers or growers who need temporary assistance following a specific adverse event.

• Rural Assistance Payment continuation form [PDF 644 KB]

  RUR02W - MAY 2024

  The Rural Assistance Payment is a Special Needs Grant for farmers or growers who need temporary assistance following a specific adverse event. Complete this form if you need to continue receiving this assistance.

S

• Security deposit claim form [PDF 196 KB]

  SHA321W - DEC 2021

  Housing providers or suppliers need to complete this form if they wish to claim against an occupant's security deposit.

• Supplier registration - online form

  Register with us if you're a supplier of goods or services and want to receive payments from MSD, e.g. being able to accept Payment Cards.

• Supplier registration - paper form [PDF 721 KB]

  ISS22W - SEP 2023

  Register as a supplier with us using the paper form if you're registering for Youth Service Payment Card, your Merchant ID has letters in it or you have problems using the online form.

• Supported Living Payment medical certificate for a person being cared for [PDF 685 KB]

  M113-MCW - JUL 2023

  For financial assistance to be given to a carer, Work and Income requires a medical certificate for the person being cared for to assure us that they require full-time care and attention. This form is to be completed by a registered health practitioner.