SuperGold Card Application - SGC01

SuperGold Card
application
A SuperGold Card gives you opportunities to stretch your money further. You’ll find all sorts of ways to
make savings every day – near you and across New Zealand.
You can find SuperGold offers by visiting supergold.govt.nz or by downloading the SuperGoldNZ app
on your smartphone or tablet.
You need to complete and return this form to us if you’re over 65 and don’t qualify for
What you NZ Super or Veteran’s Pension. You’ll also need to provide proof of who you are from
need to the table below.
provide
Proof of who you are:
If you were born in New Zealand, provide one type of official identification
that has your full legal name and your date of birth (for example, your birth
certificate, passport, driver licence, firearms licence, deed poll).
If you were born overseas, provide proof that you have a right to live
in New Zealand (for example, a citizenship certificate, a New Zealand
passport, a passport from another country with residence class visa or
proof of permanent residence).
If your name has changed, provide your marriage certificate, deed poll, or
other proof of the name change.
All people applying need to provide two more documents that help to
prove who you are (for example, a marriage certificate, bank statement,
phone or power account, driver licence).
One of the documents above must be at least two years old.
You can choose to have your photo added to your SuperGold Card after you’ve
Adding a received it.
photo to To do this, visit your nearest AA Driver and Vehicle Licensing outlet. You’ll need to take
your card your SuperGold Card and the originals of the identification you provided from the
checklist above.
SGC01W – JUN 2020 Page 1

SuperGold Card
applicant form
If you’ve received a benefit or extra financial help from Work and Income before, write your client number here
if you know it. The number can be found on your Community Services Card if you have one.
Client number
Tell us the 1 What is your full name?

names you’ve Mr Mrs Ms Miss Other
been known by
First and middle names
ATTACHMENT FOR Q1:
Provide proof of who
you are. What you need Surname or family name
to bring is explained on
page 1.
2 Is the name on your birth certificate the same as above?
No Tell us the name that is on your birth certificate Yes
First and middle names
Surname or family name
HOW TO ANSWER Q3:

3 Have you ever been known by any other name?
For example, have you
had married names, Write them all out below
No Yes
English names, changes
by deed poll, or aliases?
1.
ATTACHMENT FOR Q3: 2.
Provide your marriage
certificate, deed poll,
or other proof of any 4 What name would you like us to call you?
name change.
The name I wrote in Question 1 The name I wrote in Question 2
Other Write the full name
Page 2 SGC01W – JUN 2020

Tell us more 5 What date were you born?
about you
Day Month Year
6 Are you:
Male Female Gender diverse
7 What is your Inland Revenue tax number?
Tell us how 8 Where do you live?

we can Flat/House number Street name
contact you
HOW TO ANSWER Q8: Suburb
If you live in a rural
area, flat/house number
could include your RAPID Town/City
number, fire number,
emergency services
number.
HOW TO ANSWER Q9:

9 Is your mailing address different from where you live?
Mailing address can
include a PO Box, rural No Yes Tell us your mailing address
delivery details, or C/O
address.
HOW TO ANSWER Q10:

10 How else can we contact you? Tick the best way for
Please only give us us to first contact you
contact details you’d like Home phone ( )
us to use.
Mobile phone ( )
Other phone ( )
Email
Tell us your 11 Tick the group(s) you most identify with.

ethnicity Māori Which tribe(s) or iwi?
INFORMATION FOR Q11: New Zealand
Niuean Samoan Indian
We collect this European
information for statistics
we use in research and Other European Tokelauan Tongan Chinese
future development work.
Cook Island Māori Other Please write below Don’t want to answer

Tell us 12 Do you usually live in New Zealand?
about your
No Yes
residence
status
13 What best describes your residence status in New Zealand? Tick only one box.
HOW TO ANSWER Q12:
This means you consider New Zealand citizen Go to question 16
New Zealand your home, by birth
you’re a legal resident, Granted New Zealand
you usually live here and Date citizenship granted
citizenship
you intend to stay. Day Month Year
Go to question 14
Granted permanent Date permanent

residency residence granted
Day Month Year
Go to question 14
Other What is your residence status?
14 When did you arrive in New Zealand?
Day Month Year
15 What country were you born in?
Armed forces 16 Have you served with the New Zealand Armed Services in a war, emergency or
service peace-keeping operation?
No Go to question 20
INFORMATION FOR Q11:
You may qualify for
Yes Tick the boxes for the operations you were deployed to
a specially branded
Veteran SuperGold Card if
War Emergency Peace-keeping
you’ve served in the New
Zealand Armed Services
and have Qualifying
Operational Service. 17 Where were the theatres of operation and approximate dates?
18 What services did you serve with? Tick all that apply
Army Navy Airforce Merchant Navy – WWII
19 What is your service number?

Tell us 20 Do you have a partner?
about your
By ‘partner’ we mean someone you’re in a relationship with.
relationship
status No Go to Signature section
Yes
21 What is your partner’s full name?
Mr Mrs Ms Miss Other
First and middle names Surname or family name
22 What date was your partner born?
Day Month Year
23 What is your relationship status with your partner?

Tick one of the following boxes
Married In a civil union In a relationship
Declaration and signature

• The SuperGold Card is a personal card. This means:
– I must present the card to obtain any of it’s permitted discounts or concessions
– I can’t give my card away, lend, assign or pledge it to anyone else
– I can’t use my card if I’ve been asked to send it back and/or I’ve been sent a new card.
• I understand the conditions for the card’s use
• The information I’ve given, or that’s has been given about me in the application is true and complete.
Our online Privacy Notice tells you how we collect, use, share and keep your personal information safe. It also
has information about how you can access your personal information that we hold, and your right to ask for it to
be corrected if you think it is incorrect. To see our Privacy Notice go to workandincome.govt.nz/privacy
Applicant’s name (print) Applicant’s signature Date
Day Month Year
Go to Helper’s statement and Next steps on the next page

Helper’s statement
Complete this if you’ve helped the applicant complete this application form.
Your first and middle names Your surname or family name
Your address
Your phone number

( )
I completed this application form at the request of the person applying. They told me they understood what
they were signing. The statements and answers I have completed are true and complete as given to me by the
person applying.
Helper’s signature Date
Day Month Year
Next steps
You can either:
• Send this form and your documents (not originals) • Take this form and your documents to your
to the address below nearest Ministry of Social Development
Service Centre
Send this form to:
SuperGold Card Centre
Ministry of Social Development
PO Box 5054
Wellington 6145

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SuperGold Card

One of the documents above must be at least two years old.

SGC01W – JUN 2020 Page 1

Tell us the 1 What is your full name?

2 Is the name on your birth certificate the same as above?

No Tell us the name that is on your birth certificate Yes

First and middle names

Surname or family name

HOW TO ANSWER Q3:

Other Write the full name

Page 2 SGC01W – JUN 2020

Male Female Gender diverse

7 What is your Inland Revenue tax number?

Tell us how 8 Where do you live?

HOW TO ANSWER Q9:

HOW TO ANSWER Q10:

Tell us your 11 Tick the group(s) you most identify with.

SGC01W – JUN 2020 Page 3

Granted permanent Date permanent

Other What is your residence status?

14 When did you arrive in New Zealand?

Day Month Year

15 What country were you born in?

Army Navy Airforce Merchant Navy – WWII

19 What is your service number?

Page 4 SGC01W – JUN 2020

21 What is your partner’s full name?

Mr Mrs Ms Miss Other

First and middle names Surname or family name

22 What date was your partner born?

Day Month Year

23 What is your relationship status with your partner?

Married In a civil union In a relationship

Declaration and signature

Applicant’s name (print) Applicant’s signature Date

Day Month Year

Go to Helper’s statement and Next steps on the next page

SGC01W – JUN 2020 Page 5

Your phone number

Helper’s signature Date

Day Month Year

Page 6 SGC01W – JUN 2020

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