March 2021 | HP6653

Application for Loss of Earnings Form

Live Organ Donor

Please note: This is a llable form, If you wish to ll it out on your computer you

will need to download the form to your computer and save it before starting to ll it out.

Donor details

Family name Given name(s)

Date of birth NHI number

Samoan

Cook Island Maori

Tongan

Niuean

Indian

New Zealand residential address

Street No. and name

Town/city/postcode

Overseas residential address (if applicable)

Street No. and name

Town/city/country

I am donating as part of the kidney exchange programme

No

Recipient’s name (If you know who you are donating to or have a co-registered recipient in the kidney exchange programme)

Recipient’s address

Planned surgery date

You must send this application form to us before the date of your surgery

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Hospital where donation will take place

Hospital

Compensation for loss of earnings

Compensationisavailabletoeligiblelivedonorswhotakeunpaidleavetohavesurgeryandrecover.Youcanndout

more about eligibility for earnings compensation and how compensation is calculated from the ‘Compensation for

loss of earnings’ on the Ministry of Health website www.health.govt.nz

Employment type (tick appropriate boxes)

Full-time employment Self-employed Voluntary employment Shareholder employee

If Yes, what are the dates of the appointments?

Plans for returning to work

Do you plan to return to work on reduced hours while you recover from surgery?

If Yes, what is the date of your anticipated return to work on reduced hours?

What average reduced weekly hours will you work?

What is your aniticpated return to work on your usual hours?

What are your usual average weekly hours?

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March 2021 | HP6653

Self-employed (Please attach your most recent tax return)

Overseas earnings (Pleaseattachyourmostrecenttaxreturnfromtherelevanttaxauthorityinthatcountryandaveried

translation if this document is not in English)

Start date with employer

Manager name Payroll contact name

Phone number Phone number

Email address Email address

Payment details (New Zealand bank account)

Nominated bank account(Pleaseattachaveriedcopyofthebankaccountdetails)

Bank Branch Account Name

Bank account number IRD number Student loan

No

Tax code (Provideyourprimarytaxcodeandlloutataxcodedeclaration(IR330)fromwww.ird.govt.nz)

IfyoucontributetoKiwiSaver,pleasecompleteaKiwiSaverdeductionform(KS2)fromwww.ird.govt.nz

Other superannuation scheme:

Doyoucurrentlyreceiveabenetinadditiontoworking?

No

IfYes,pleaseprovideamountofyourbenetperweek,withoutFamilyTaxCredit

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to correctly compensate me for lost earnings during my recuperation from donor surgery. For this reason, I

consent to

any necessary information being shared between the Ministry of Health and:

• the Ministry of Social Development and/or Inland Revenue Department and relevant clinical agencies in

order to calculate the correct amount of compensation I should be paid, to help the Ministry of Health make

payments at the correct time and for the correct period of time.

• my employer if any, to help the Ministry of Health to make payments for the correct period of time and

amount.

I understand that:

• this information is being collected in order to correctly compensate me for lost earnings during my

recuperation from donor surgery

• underthePrivacyAct1993,IhavetherighttorequestaccesstoallinformationtheMinistryofHealthholds

about me and to request corrections to that information

• I am responsible for contacting Inland Revenue Department to discuss my child support obligations

• IunderstandthattheMinistryofHealthwillnotbeoeringpayrollgivingdonations.

I,

• the organ removal and transplant will occur in New Zealand or as part of the Australian and New Zealand

Kidney Exchange Program as I am registered with the New Zealand Kidney Exchange Programme

• I will forego earnings as a result of taking unpaid leave or otherwise ceasing employment to allow for my

recuperation from the donor surgery, and/or to attend a medical appointment immediately prior to my