NEW ZEALAND RED CROSS
NOVEMBER 2016 EARTHQUAKE
DAMAGED HOME GRANT APPLICATION FORM
This grant is for households whose home became unsafe to live in after the November 2016 earthquake, either
because it was damaged or because it was placed at risk (for example, by landslide dam). The aim is to assist
households in meeting the increased costs associated with this situation.
The grant is targeted at those who lived in Hurunui, Kaikōura, or Marlborough Districts or Wellington Region:
1. whose primary residence (the place they usually live) has been red- or yellow-stickered, OR
2. who have been required to evacuate their primary residence due to a risk relating to the earthquake.
Only one application will be considered per household. A household contains those who usually lived at the
affected address, and not landlords or businesses. If approved, the grant will be a one-off payment of $1,000.
Applications must be received by 5p.m. Friday 10 February 2017.
Applicant’s details:
Title: (circle one) Mr/Mrs/Ms/Miss/Dr/Other _________ Surname/Family name: ___________________________
Given names: _______________________________________________________________
⃝ Male
⃝ Female
Usual residential address as at 14 November 2016: (include POSTCODE) __________________________________
______________________________________________________________________________________________
Current residential address, if different from above: (include POSTCODE) _________________________________
______________________________________________________________________________________________
Current postal address: (if not your current residential address) ___________________________________________
______________________________________________________________________________________________
Daytime phone number: ________________________ Other phone number: _____________________________
(include area code)
Email address: __________________________________________________________________________________
Please select as many as apply to you: (Optional)
New Zealand Māori
Chinese
Filipino
German
NZ European/Pākehā
Japanese
Samoan
Italian
Australian (European descent)
Korean
Tongan
Dutch
British/Irish
Malaysian
Fijian
Indian
Other: _______________________________________________
Note: This information is for demographic purposes only.
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VERSION 1. AS AT 14.12.2016
Applicant Situation:
1. If you received a Council building inspector’s certificate (“sticker”) for your primary residence (the residential
building you usually lived in as at 14 November 2016), what colour is your certificate?
⃝ Red (No access)
⃝ Yellow (Restricted access)
⃝ Green/White (Full access)
2. Have you been required to evacuate your primary residence for seven days or more, due to risk to the
dwelling (for example, risk from a ‘landslide dam’ or neighbouring building)?
⃝ Yes
⃝ No
In all cases the damage or risk must be due to the earthquake of 14 November 2016 and/or subsequent
aftershocks.
Details of other people usually living with you at your residential address
as at the day of the earthquake (14 November 2016):
Name
Male/Female
Relationship to
applicant
Date of birth
(if known)
Each household is only eligible for one 2016 Damaged Home Grant. In this case ‘a household’ is taken as all
people living at the same residential address, as at the date of the earthquake, 14 November 2016. This includes
flats and other shared living situations, and applies even if some people are now living at different residential
addresses.
In order for Red Cross to process your application, please attach the following:
⃝ Verification of your address, in the form of a bank account or utilities bill addressed to you by name at
your usual residential address and dated between 1 September and 30 November 2016:



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Bank account; OR
Electricity or gas account; OR
Telephone account.
VERSION 1. AS AT 14.12.2016
⃝ Verification that your primary residence was unsafe to live in:


A copy/photo of a red or yellow Council building inspector’s certificate; OR
A copy/photo of an evacuation notice.
⃝ Verification of your bank account details for payment, including your name and account number:


A printed bank deposit slip for this account; OR
A copy of a recent bank statement.
Note that it is possible further information will be required to process your application.
Declaration:
I/we declare that the information provided above is true and correct. I/we understand that this application may
be declined if any of the above information is not correct, and that New Zealand Red Cross reserves the right to
accept or decline this application for other reasons at its discretion. I/we acknowledge that in a shared living
situation, it is my/our responsibility to ensure this application is made in consultation with other occupants.
I/we grant permission for New Zealand Red Cross to contact local authorities and/or other relevant government
or non-government organisations for the purpose of considering this application, and I/we authorise any such
authority or organisation to disclose information about me to New Zealand Red Cross for this purpose. I/we also
understand that the Privacy Act 1993 entitles me to have access to and if necessary request correction of the
information.
Signature of applicant: _______________________________
Date: ________________
All grants are subject to meeting the relevant criteria and funding availability.
Please send your application to New Zealand Red Cross in one of the following ways:
Scan and email:
[email protected]
Post to:
New Zealand Red Cross Grants Team
PO Box 217
Christchurch Mail Centre 8140
Please keep a copy of your application for your records.
OPTIONS FOR PROVIDING FEEDBACK:
We would be happy to hear your feedback regarding this application process.
0508 4GRANTS (4472 687)
www.redcross.org.nz/contact-us/
P.O. Box 217
Christchurch Mail Centre 8140
[email protected]
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VERSION 1. AS AT 14.12.2016