Credit Union KiwiSaver scheme –
Serious Illness – Request for withdrawal of funds
Issued by Mercer (N.Z.) Limited as Administration Manager of the Scheme.
Definition of Serious Illness
The KiwiSaver Act 2006 defines serious illness to mean an injury, illness or disability –
that results in the Member being totally and permanently unable to engage in work for which he or she is suited by reason of experience,
education, or training, or any combination of those things; or
that poses a serious and imminent risk of death.
The information contained within this form will be used by the Trustees of the Credit Union KiwiSaver scheme to determine whether or not you meet
the criteria for a claim based on Serious Illness, as defined.
If you do not meet the requirements for a withdrawal on the grounds of serious illness, but your illness is causing significant financial hardship,
you may still make a claim on the basis of ‘Significant Financial Hardship’ by completing the Significant Financial Hardship claim form, available on
Procedure for completing this form
You must complete this form personally.
1. Complete your personal details, how you would like to receive payment and the amount you would like to withdraw.
Steps 1, 2 and 3 of the form must be completed by you.
2. Complete the Statutory Declaration
The Statutory Declaration (Step 4) must be made in front of a Lawyer, Justice of the Peace, Notary Public or other person authorised to take Statutory
3. Ask your doctor to complete the Medical section
4. Return the completed form to Mercer
Credit Union KiwiSaver scheme
PO Box 1849
The Trustees will make a decision whether or not to approve your claim. The Trustees may require further information from you. If the Trustees
approves your claim, you will be advised and payment will be made in accordance with your instructions.
Privacy Act 1993
The information comprised in this form and requested as attachments is