Application worksheet
A printable version of Opotiki District Council - Mayoral Disaster Relief Fund's application questions, extracted from their official form. Use it to plan your answers - then submit through the funder's real form.
View the original PDF →Application worksheet
Ōpōtiki District Mayoral Disaster Relief Fund Application for grant
Opotiki District Council - Mayoral Disaster Relief Fund
This worksheet mirrors the questions on the funder's official application form. It is NOT the official form. Submit your final answers through https://www.odc.govt.nz/our-services/civil-defence-and-emergency-management/mayoral-disaster-relief-fund.
Please complete this form to apply for a grant from the Ōpōtiki District Mayoral Disaster Relief Fund.
1. Application details
Name of applicant:*
Contact phone number:*
Email address:*
Which of this best describes you?*
2. Application property details
Residential address prior to disaster event*
Current residential address*
Mailing address (If different from above)
Number of whānau/family members affected
Please fill out this section if you are a family.
Name of community organisation, volunteer group, small business or marae
Please fill out this section if you are a community organisation, volunteer group, small business or marae.
Physical address of community organisation, volunteer group, small business or marae
Please fill out this section if you are a community organisation, volunteer group, small business or marae.
NZBN number if applicable
The NZBN provided will be used to look up the following information: New Zealand Companies Register Information, NZBN, entity Name, registration date, entity status and type, registered address and office address.
Is your business GST registered?
GST number if registered
Location of marae
Please fill out this section if you are a marae.
3. Details of damage or loss and assistance sought
Explain in detail what damage or loss you experienced or support you’ve provided to the Disaster Event response and/or recovery and what assistance you are seeking.*
Please attach supporting information for verification of costs if available (quotes, receipts, invoices).
State details of any assistance you have already received or will receive from any other agency (Including insurance claims)*
What amount of assistance do you require?*
Have you made a claim with Natural Hazards Commission Toka Tū Ake?*
Is the affected property owned by you or rented?*
Insurance status*
4. Privacy Statement
Ōpōtiki District Council Mayoral Disaster Relief Fund Privacy Statement
Documents to attach
- Supporting information for verification of costs if available (quotes, receipts, invoices)
- Bank account proof
Declarations
- I certify that the information provided in this application is correct and if I provide false information, I understand that my application will be rejected.
- I give permission for the Ōpōtiki District Council to verify the information provided with any other agencies that may be involved.
- I have read and understood the above privacy statement.
- I confirm that any personal information I include about any other person(s) in this application has been provided with their permission and can be used for the purposes identified above.
Signature
Date
Worksheet generated by All Too Human (alltoohuman.nz/grants). Source: official PDF. This is not an official submission form.