APPLICATION FORM FOR TENANCY OF A HOUSING UNIT FOR THE ELDERLY

Please circle your preferred location/s:

Amberley Waikari Hanmer Springs Cheviot

  1. Full Name(s)

Surname ______

First Name ______

______

  1. Present Address ______

______Phone:______

  1. Date of Birth ______
  1. How long have you lived in the Hurunui District? ______
  1. If you are not currently living in the Hurunui District do you have family members living in the District?

______

  1. Current living arrangements:
  2. Do you occupy whole house, flat, rooms, or are you boarding?

______

(b) Number of rooms occupied by you______

(c)Length of time in present premises ______Years ______Months

(d)Are these premises rented? ______Weekly rental $______

(e)Are you the sole occupant(s)? ______

(f)If others occupy the premises, what is the relationship to you?

______

  1. Property owned by you:
  2. Address of Property ______
  1. Name of occupant (if not self) ______
  1. If you are not the occupant, please state why not ______

______

  1. Do you receive rentals? ______If so, weekly amount $______
  1. Have you sold any property within the last five years? ______
  1. If so, address of the property sold ______
  1. Sale Price $______Mortgage(s) held $______
  1. Income

Applicant 1 Applicant 2

(a) Are you in receipt of a benefit or pension? ______

If yes, what type of benefit/pension? ______

Amount of benefit or pension $______$______

(b) Do you receive any other income? ______

If so, please state amount received per week, from –

Wages/Salary ______

Accident Compensation ______

Interest (per annum) ______

Maintenance ______

Other ______

(state source)

  1. Assets:

What assets do you own? (Approximate value excluding car, furniture and personal effects)

Applicant 1 Applicant 2

(a)Cash (on hand and in bank)______

(b)House and other property______

(c) Investments______

(d)Other______

(Please state)

  1. Next of Kin:

Name ______

Address______

Telephone no: ______

  1. Are you able to care for yourself and if not, have you friends or relatives who would care for you and the flat?

______

  1. Medical Advisor:

Name of Doctor: ______

  1. I/We do solemnly and sincerely declare that the particulars supplied are correct in every detail and I/We make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957.

DECARED AT ______this______day of ______200

Signature(s) ______

Before: ______A Solicitor of the High Court of NZ

A Justice of the Peace in NZ

PRIVACY ACT PROVISIONS :

The information you provide on this application for housing will be collected and held by the Hurunui District Council. The information is collected for the purposes of assessing your eligibility for housing assistance.

You have a right of access to personal information and to seek any correction you think necessary to ensure accuracy.

You should provide complete information in answer to each question unless otherwise advised, regardless of whether you consider it relevant.