WHAKATANE DISTRICT COUNCIL APPLICATION FOR PENSIONER UNIT

Transcription

1 WHAKATANE DISTRICT COUNCIL APPLICATION FOR PENSIONER UNIT Address all correspondence to: Community Facilities Administrator Whakatane District Council, Private Bag 1002, Whakatane 1. APPLICANT(S) DETAILS First name Surname File Date Middle name(s) Known as Physical address House/unit number RD Number Town Street Suburb/area Post code Postal Address for service documents (if different from physical address) Daytime contact name and telephone number Home phone Mobile phone address Marital status Please state if you are: Accommodation required Single Separated/divorced Single unit Work phone Married/De facto Widowed Double unit NAME OF SPOUSE/PARTNER (if double unit required) First name Length of residence in Whakatane Occupation status EXISTING ACCOMMODATION Surname Applicant Spouse/partner (a) In what type of accommodation are you residing? (Please tick one) Unit House with family House Bach Room Caravan (b) Do you pay rent or board? Yes No If yes, how much? $ (c) How long have you lived in these premises? (d) If you need to live near other family in the District, please give reasons (e) Please state fully your current circumstances and why you consider your present accommodation is unsuitable. Page 1 of 5 25/01/2012

2 APPLICANT S ABILITY TO LIVE INDEPENDANTLY Please complete and sign the consent at the top of the attached Independent Living Form. You need only fill in the top of the form and return it with your application as the Council will contact your doctor directly for the required information. The information requested will assist the Council to determine whether you are capable of independent living, such that there would not be any significant risk of harm to yourself or to others living in a Council pensioner unit village. Consent on independent living form signed UNIT LOCATION PREFERENCE Please signify any preference for a particular block of units. (It must be understood that the Council will try to accommodate your preference, but this depends on availability of units in your preferred location.) Yes No Alice Stone Flats (WHK) Allandale (WHK) Murupara Lovelock (WHK) Veronica Flats (WHK) No particular preference ASSETS (Combine the assets if more than one applicant): Cash $ Vehicle $ Houses $ Land $ Investments $ Other assets $ INCOME Main source (give details) TOTAL: Per week / fortnight (delete one) PREVIOUS TENANT HISTORY ATTACHED ARE TWO REFERENCES FROM PREVIOUS LANDLORDS OR IF THE APPLICANT HAS NOT PREVIOUSLY BEEN IN A TENANCY SITUATION TWO CHARACTER REFERENCES MUST BE SUPPLIED. Name of references Address Telephone NEXT OF KIN Name Address Telephone Relationship Page 2 of 5 25/01/2012

3 I (full name) STATUTORY DECLARATION (To be completed by the applicant) of (full address) (nature of occupation) do solemnly and sincerely declare that all statements made and all particulars contained in the foregoing application are, to the best of my knowledge, information and belief true, full and correct in each and every particular, and I make this solemn declaration conscientiously believing the same to be true, and under and by virtue of the Oaths and Declarations Act SIGNATURE OF APPLICANT Declared at this day 200 before me: A solicitor of the high court of New Zealand A justice of the peace of the high court of New Zealand Court registrar Postmaster or Other office duly authorised to take statutory declarations Please ensure you have attached two references from previous landlords OR if the applicant has not previously been in a tenancy situation two character references must be supplied. For the matters that are to accompany this application, see regulation 8(2) of the Sale of Liquor regulations Please note that without all details in the application form being completed and the statutory declaration being signed your application will not be accepted or processed. Pursuant to the Privacy Act 1993 it is brought to your attention that the personal information contained in this form is being collected to assist the Council in processing your application. You have the right of access to and correction of this information subject to the provisions of the Privacy Act Page 3 of 5 25/01/2012

4 INDEPENDENT LIVING FORM I, (Name of applicant) give my consent for my Doctor to complete the information requested in the form set-out below and forward it to the Property Administration Officer at the Whakatane District Council. Signature Date My doctor s name is Phone No Address of doctor FOR THE DOCTOR TO COMPLETE: The applicant has applied for a tenancy in a Council pensioner unit. These are in groups of small one bedroom, self-contained units which require the applicant to have the ability to live independently and in close proximity with a community of elderly people. The information requested will assist the Council to determine whether the applicant is capable of independent living, such that there would not be any significant risk of harm to the applicant and that they will be able to live harmoniously and in a nondisruptive manner with others living in the Council pensioner unit village. Name of patient Has the patient suffered from / is suffering from: (please give details) Stroke Heart disease or conditions Respiratory disease Psychiatric or nervous disorder (please indicate type of illness/disorder) Arthritis or osteoporosis Diabetes Alcoholism Other Page 4 of 5 25/01/2012

5 Please comment on the following: 1. Physical & mental condition of the applicant and their ability to cope on their own 2. Please confirm that the applicant would be able to live harmoniously and in a non-disruptive manner with others living in the Council pensioner unit village and not cause disturbances or friction with others. 3. Degree of mobility and type of disability (if any) 4. Any condition that could affect the applicants ability to live alone like heavy drinking, violent or threatening behaviour towards others. District nurse Psychiatric support Home care-givers Home-help Meals on wheels Other Current Needed Smoker / Non-smoker Smoker Non-smoker Doctor s signature Please note that without sufficient details, the application may not be accepted PLEASE RETURN TO: Community Facilities Administrator Whakatane District Council Private Bag 1002 WHAKATANE Page 5 of 5 25/01/2012