Application worksheet
A printable version of Waipa 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
Waipā District Mayoral Disaster Relief Fund Application for grant
Waipa 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.waipadc.govt.nz/our-services/grants-and-funding/mayoral-disaster-relief-fund.
Please complete this form to apply for a grant from the Waipā 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.
Adults
Please fill out this section if you are a family.
Children
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.
3. State details of any assistance you have already received or will receive from any other agency (Including insurance claims)
Insured
Underinsured
Uninsured
4. Additional Information
Please attach proof of your bank account when you send in your application*
NZBN number if applicable
Is your business GST registered?
GST number if registered
Location of marae
Please fill out this section if you are a marae.
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*
Have you made a claim with Natural Hazards Commission Toka Tū Ake? (Previously known as EQC)
Is the affected property owned by you or rented?
Insurance status
What amount of assistance do you require?*
5. Privacy Statement
Documents to attach
- proof of your bank account showing your account name and number - for example, a deposit slip, bank statement, or online banking screenshot
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 Waipā 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.