By Leon Cook,2014-04-08 21:17
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You must complete this form in order to request financial assistance from the Mayor’s Welfare - Earthquake Relief


    ; You may only submit one application form per household.

    ; The Mayor’s Welfare – Earthquake Relief Fund will not reimburse for any work/repairs already completed

    ; The Mayor’s Welfare - Earthquake Relief Fund will not fund relocation out of the Christchurch area

    ; Please attach all earthquake related repair quotes and any other relevant information to the completed application

    form at the time of submission

    ; Please provide a copy of your proof of identification (e.g. Driver’s Licence, passport, Community Services card)

    ; Please provide proof of your address (e.g. power bill, bank statement)

Please ensure you complete as many fields as possible.

    If you are applying online please email this completed form to:

    Please call 941-8999 if you have any questions regarding this application form

     Use the [Tab] key to move between the sections in this form.

    1. Applicant Name: (If you are submitting on behalf of someone please provide your name and contact details and the reason)

2. Current Physical Address: (current/temporary)

3. Are you a tenant or ratepayer owner of this location:

4. Previous Address: (if you had to relocate due to earthquakes)

5. Are you a tenant or ratepayer owner of this location:

6. Postal Address: (current/temporary)

7. What Zone is your previous address located in:

    Please indicate the colour Please indicate sticker colour

8. Contact details

     Phone number Email Address

9. Is your intention to remain/move back into your previous address?

10. Please indicate your other household members:

People that live with you Your relation to them Are they a dependant of yours

11. Purpose.

    Please tell us the purpose of your application and explain the hardships you face as a result of the

    earthquakes. Please detail how you would use the financial assistance if provided. Please provide as

    much detail as possible to support your application attaching any files or images relevant to your

    request. If you require more space please prepare a separate document and attach it to this form.

12. Do you have house insurance?

13. Do you have contents insurance?

14. Do you have income protection insurance?


15. Do you have health insurance?

16. How much do you require in financial assistance? (please briefly list the types of repairs/costs your require assistance with and please provide at least two quotes for any work required by attaching them to this application at the time of submission (quotes by Tradesmen/repair companies)

    Item: Cost: Quotes obtained from:

    17. Please list any assistance you have received with regards to the earthquake. Please indicate

     which agencies’ and the amount received. (e.g. Salvation Army, insurance)




18. Please list any assistance you have been denied and provide supporting documentation (e.g. Insurance coverage denial letter)

    19. Please indicate the general timeline for when financial assistance is required:

    20. If you have been referred by any agencies to this fund please indicate which agency:


The recipient(s) acknowledges that the Council may include details of the grant in public announcements or


These questions are optional and intended to help provide the Council with demographic information:

21. What is your age:

     15-24 25-49 50-64 65+

22. Ethnicity and Employment status:

    What is your ethnicity: What is your employment status:

23. I/We declare that the information supplied in this application is true and correct.

    Name Date


    23. Please verify you have provided all of the following:

    ; Application has been signed

    ; Necessary quotes are attached

    ; Your proof of identification

    ; Your proof of address

    ; Your contact information

    ; Clear contact information if submitting this form on behalf of someone


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