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www.dunedin.govt.

nz

Application
Form

Rental Housing

Application for

Rental Housing
Please fill in the shaded boxes. Once the form is completed, please telephone the Council and
make an appointment to discuss your application with a Housing Officer.
They can also assist you in completing the form or answer any questions you have.
Telephone 474 3737.

11. Statutory Declaration (to be completed by applicant/s)
I/We (full names)

1. People to be Housed
Title

of (full address)

a)

Surname

First Names

Kaplish

Mr

Date of Birth
25-10-1970

Mohinder

b)
Current Address:

(nature of occupations)
do solemnly and sincerely declare that all statements made and all particulars contained in the foregoing
application are, to the best of my/our knowledge, information and belief true, full and correct in each and
every particular and I/we make this solemn declaration conscientiously believing the same to be true and
under and by virtue of the Oaths and Declarations Act 1957.

Signature of Declarant

Signature of Declarant

North East Valley
Dunedin

Contact Phone No:

0211015532

2. Existing Accommodation
Are you:

Declared at

37 Glendining Avenue

Declared at

Renting

Living in own home

this

day of:

this

day of:

20

before me:

20

before me:

To be signed in the presence of:

To be signed in the presence of:

A Housing Officer in the service of the Dunedin
City Council duly authorised to take Statutory
Declarations.

A Housing Officer in the service of the Dunedin
City Council duly authorised to take Statutory
Declarations.

A Solicitor of the High Court of New Zealand

A Solicitor of the High Court of New Zealand

A Justice of the peace in and for New Zealand

A Justice of the peace in and for New Zealand

Boarding

(tick in box)

How much rent/board do you pay (weekly):
How long have you lived there:

(tick in box)

(tick in box)

In emergency accommodation (tick in box)

135
One Year

Have you received notice to vacate from your landlord:

Yes (tick in box)

No (tick in box)

Do you need to give notice to your landlord?

Yes (tick in box)

No (tick in box)

How much notice?

3. Please attach two written character references from two citizens other than
relatives who have known you for twelve months or longer.

Address of Property: Value of applicant’s share: $ Total value of the Property: $ Is the property mortgaged: Yes (tick in box) If yes.Per annum a) Social Welfare Benefit $ 0 Type Are you a New Zealand Citizen: b) Salary/Wages $ 437 If no.85 Name: Agency: 03 0915 0393228 00 $ 15 (Approx) Bank Account / Investment Other Assets (excluding personal effects and furniture): 10. New Zealand Residency 4. General Practitioner Name: If yes. Address of Property: Practice: 9. are you permitted to reside in New Zealand permanently: c) Total $ 437 437 Please supply a certificate of earnings from your employer 5. Gross Income . 8. what is the principal outstanding: No (tick in box) $ b) Have you owned or had a financial interest in any property in the last five years? Yes (tick in box) No (tick in box) Yes (tick in box) No (tick in box) Yes (tick in box) No (tick in box) If you are not a New Zealand Citizen. friend etc . 7. Support Agency Assistance When was it sold: What was the sale price: $ Value of your share: $ Do you receive assistance from a support agency: e. but are allowed to reside in New Zealand permanently. Assets and Liabilities (for all applicants) a) Do any applicants currently own or have a financial interest in any house. A criminal charge is one in which it is alleged that you have broken the law in some way. please bring your immigration documents with you when you come in for an interview. CCS.g. Criminal Offences Please indicate whether or not you have been convicted of any criminal offence that is punishable Yes (tick in box) No (tick in box) by imprisonment or if you have any criminal charges pending. please list: Telephone: Relationship: e.) If “Yes” please provide details: I consent to the Dunedin City Council making enquiries to verify the information in my application including police checks and credit checks and recognise that all enquiries will be conducted on a confidential basis and that the Dunedin City Council has the right to maintain the confidentiality of this information. Next of Kin $ 0 Name: Motor Vehicle: $ d) Do you have any loans or hire purchase agreements: No (tick in box) Yes (tick in box) No (tick in box) Address: If yes.6. flat or other property in New Zealand or overseas? Yes (tick in box) No (tick in box) If yes.g. please give details: c) Please list all bank accounts and investments: Yes (tick in box) Name: Agency: Current Balance Name: Agency: 06 0909 0317165 00 $ 341. daughter. (We do not include traffic offences other than drink driving or convictions that are subject to the Criminal Records (Clean Slate) Act 2004. Presbyterian Support. District Psychiatric Nurse If yes. son.

New Zealand Residency 4. daughter. but are allowed to reside in New Zealand permanently. A criminal charge is one in which it is alleged that you have broken the law in some way. son. flat or other property in New Zealand or overseas? Yes (tick in box) No (tick in box) If yes. are you permitted to reside in New Zealand permanently: c) Total $ Please supply a certificate of earnings from your employer 5.g. CCS. 7. Support Agency Assistance When was it sold: What was the sale price: $ Value of your share: $ Do you receive assistance from a support agency: e. Criminal Offences Please indicate whether or not you have been convicted of any criminal offence that is punishable Yes (tick in box) No (tick in box) by imprisonment or if you have any criminal charges pending. please bring your immigration documents with you when you come in for an interview. District Psychiatric Nurse If yes. Dunedin 9. 8. Gross Income . Address of Property: Value of applicant’s share: $ Total value of the Property: $ Is the property mortgaged: Yes (tick in box) If yes. what is the principal outstanding: No (tick in box) $ b) Have you owned or had a financial interest in any property in the last five years? Yes (tick in box) No (tick in box) Yes (tick in box) No (tick in box) Yes (tick in box) No (tick in box) If you are not a New Zealand Citizen. please list: Telephone: Relationship: 0204077700 Friend e. Assets and Liabilities (for all applicants) a) Do any applicants currently own or have a financial interest in any house. friend etc . Next of Kin $ Name: Motor Vehicle: $ d) Do you have any loans or hire purchase agreements: Yes (tick in box) No (tick in box) Address: Lovepreet Kang Duncan Street If yes.) If “Yes” please provide details: I consent to the Dunedin City Council making enquiries to verify the information in my application including police checks and credit checks and recognise that all enquiries will be conducted on a confidential basis and that the Dunedin City Council has the right to maintain the confidentiality of this information. Presbyterian Support. (We do not include traffic offences other than drink driving or convictions that are subject to the Criminal Records (Clean Slate) Act 2004. General Practitioner If yes.Per annum a) Social Welfare Benefit $ Type Are you a New Zealand Citizen: b) Salary/Wages $ If no. please give details: c) Please list all bank accounts and investments: Bank Account / Investment Yes (tick in box) Name: Agency: Current Balance Name: Agency: $ Name: Agency: No (tick in box) $ Other Assets (excluding personal effects and furniture): 10.g. Address of Property: Name: Dr Raghupati Practice: Community Support.6.

Existing Accommodation Are you: Declared at Date of Birth b) Dunedin Signature of Declarant First Names a) North East Valley (nature of occupations) Surname Declared at Renting Living in own home this day of: this day of: 20 before me: 20 before me: To be signed in the presence of: To be signed in the presence of: A Housing Officer in the service of the Dunedin City Council duly authorised to take Statutory Declarations. full and correct in each and every particular and I/we make this solemn declaration conscientiously believing the same to be true and under and by virtue of the Oaths and Declarations Act 1957.govt.nz Application Form Rental Housing Application for Rental Housing Please fill in the shaded boxes.www. 11.dunedin. please telephone the Council and make an appointment to discuss your application with a Housing Officer. People to be Housed Mohinder Pal Kaplish 37 Geldining Ave Title Current Address: Security do solemnly and sincerely declare that all statements made and all particulars contained in the foregoing application are. . A Housing Officer in the service of the Dunedin City Council duly authorised to take Statutory Declarations. Signature of Declarant Contact Phone No: 2. They can also assist you in completing the form or answer any questions you have. Once the form is completed. Please attach two written character references from two citizens other than relatives who have known you for twelve months or longer. Statutory Declaration (to be completed by applicant/s) I/We (full names) of (full address) 1. to the best of my/our knowledge. information and belief true. A Solicitor of the High Court of New Zealand A Solicitor of the High Court of New Zealand A Justice of the peace in and for New Zealand A Justice of the peace in and for New Zealand Boarding (tick in box) (tick in box) (tick in box) In emergency accommodation (tick in box) How much rent/board do you pay (weekly): How long have you lived there: Have you received notice to vacate from your landlord: Yes (tick in box) No (tick in box) Do you need to give notice to your landlord? Yes (tick in box) No (tick in box) How much notice? 3. Telephone 474 3737.