$3k to Work
incentive payment application
The $3k to Work incentive payment is to help you relocate to another area in
New Zealand to take up full-time employment. To get this, you must be receiving a
benefit, or have applied and be eligible for one. There are also some other conditions.
Write your client number here. It can be found on your Community Services Card.
Client number
Your details
1
First and middle names
ATTACHMENT FOR Q1:
Please bring proof of your
identity when you apply. For
example your passport or
driver licence.
What is your full name?
2
What date were you born?
Day
HOW TO ANSWER Q3:
3
If you live in a rural
area, flat/house number
could include your RAPID
number, fire number,
emergency services
number.
Surname or family name
Month
Year
Where do you live now?
Flat/House number Street name
Suburb
Town/City
HOW TO ANSWER Q4:
4
Mailing address can
include a postal box (PO
Box), rural delivery details,
or C/O address.
HOW TO ANSWER Q5:
Please only give us
contact details you would
like us to use.
5
Is your mailing address different from where you live now?
No
Tell us your mailing address
Yes
How else can we contact you?
Home phone
( )
Mobile phone
( )
Other mobile phone
( )
Tick the best way for
us to contact you
Email
LAB1020W – FEB 2016
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Your new job
6
What are the details of the business you will be working for?
Business name
ATTACHMENT FOR Q6:
You will need to provide
proof of your new job.
Business address
Examples of proof
include:
Street number
Street name
• signed employment
contract
Suburb
• letter of offer from the
employer.
Town/City
Employer’s name
Employer’s contact details
Phone
( )
Mobile phone
( )
Fax
( )
Email
7
What industry is the job in?
8
What date do you start?
INFORMATION FOR Q7:
Examples of industries
include:
• construction
• hospitality
• horticulture, etc.
Day
9
Month
Year
What is your before-tax pay rate?
Weekly
$
10
12
Choosing YES will
mean that you will not
have to make payments
to your benefit or Student
Allowance debt for three
months, when you start
full-time work.
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Yes
Is your employment expected to last for more than 91 days?
No
HOW TO ANSWER Q12:
Monthly
Is your employment for more than 30 hours a week?
No
11
Fortnightly
Yes
If you are cancelling your benefit, do you want to apply for the three months
Debt Recovery Suspension?
No
Yes
Not applicable
LAB1020W – FEB 2016
13
Your new
accommodation
Where will you be living when you move to the new area?
Flat/House number Street name
Suburb
Town/City
HOW TO ANSWER Q14:
14
Mailing address can
include a postal box (PO
Box), rural delivery details,
or C/O address.
HOW TO ANSWER Q15:
15
Please only give us
contact details you would
like us to use.
Will your mailing address be different from where you will live?
No
Tell us your mailing address
Yes
What will your contact details be when you are in the new area?
Tick the best way for
us to contact you
Home phone
( )
Mobile phone
( )
Other mobile phone
( )
Email
Declaration and signature
By signing this form I understand that:
• Work and Income can recover the $3k to Work incentive payment if I leave my job without a good and
sufficient reason and return to benefit or study within 91 days of starting work, or do not use the payment for
the purposes for which it was granted (for example, if I do not relocate or start work).
• I can only receive one $3k to Work or $3k to Christchurch incentive payment in a 52 week period.
• Work and Income may contact my employer for confirmation of my employment and/or to confirm that I am
in employment for more than 91 days.
• The information I have given is true and complete.
Your name (print)
Your signature
Date
Day
LAB1020W – FEB 2016
Month
Year
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