Te Hiranga Tangata / Work and Income

Printed from: https://services.workandincome.govt.nz

Printed: 22 November 2024

Residential Care Subsidy historic review request

About this form

Use this form to request a historic review of a financial means assessment.

The information you provide in this form will be used to check whether you've been affected by the May 2019 Court of Appeal decision in relation to Residential Care Subsidy.

If you're an agent you can complete this form on someone's behalf. We'll ask for proof of this if we don't already have it.

If you're an executor of their estate, an example of proof is a copy of their will. Once you've completed the form - email this proof to us at: RCS_historic_review@msd.govt.nz

Please note the questions in this form may change dynamically based on your answers to previous questions.

Keeping a copy of this form

After you submit the form, you’ll see a confirmation page with all the info you entered. If you want to keep a copy, you can print that page or save it as a PDF using the browser’s print function.

Who you are

This form can be completed for yourself, or if you're an agent, on behalf of someone else.

Are you completing this form for yourself or on behalf of someone else? (required)
Agent's details

Questions saying 'you' refer to the person in care (MSD's client)

Client details
You can find this on your Community Services Card, SuperGold Card or by requesting a client number online
Contact information

How do we get in touch with you about this form?

Preferred contact method (required)
This must be a valid New Zealand number.
Residential care subsidy details
Rest home or private hospital address
If you're not sure what the postcode is for this address, you can find it with the NZ Post postcode finder
This includes selling an asset, a change in your income or relationship status
Apart from your own money, was there any other money you could have used? (required)This includes whether you could have used money from a trust, estate, family member or someone else to pay for your care. If there was, we may ask why you chose not to access that support. If yes, we will be in touch to talk with you about this
Please include the name of the person or entity (for instance trust or estate) who gave the money and their relationship to you.
For instance was it weekly, monthly or a one-off payment? And for how long - was it the whole time in residential care or just some of the time?
Please include the name of the person or entity (for instance trust or estate) and their relationship to you.
For instance was it weekly, monthly or a one-off payment? And for how long - was it the whole time in residential care or just some of the time?
Was there a formal, written agreement? (required)We might be in touch to talk with you about this.
Past financial support means money that doesn't need to be paid back. This includes receiving free accommodation, distributions of income and/or assets from a trust or an estate, or someone paying costs on your behalf.
If yes tell us about that financial hardship, for instance the family had to re-mortgage their house to pay for care.
Bank account details
If we owe you a refund, we'll pay it into the bank account we already have for you.
If the client has died, we'll pay the executor or administrator of their estate. If this is you. please ensure you provide us with evidence of this. This can be done with a copy of the will or probate which you can email to us at RCS_historic_review@msd.govt.nz if you have this ready now.
Declarations