Affordable Rentals Form | Tūwharetoa Settlement Trust

First Name *

Last Name *

Street Address

City *

Email Address *

Phone *

How many adults (aged 18+) including yourself live in your whare? *

How many children (aged 0-17years) live in your whare? *

Do you have any significant health problems?YesNo

Do you have any safety/ accessibility concerns?YesNo

Please share your current situation and why you are leaving this address?

What sort of whare are you looking for? *

What is your main source of income? (please select one only)

What category best describes your gross (before tax) family household income for the past 12 months?Less than $40,000$40,000 - $54,999$55,000 - $64,999$65,000 - $74,999$75,000 - $84,999$85,000 - $99,999over $100,000

Do you have money saved (including Kiwisaver)?

By signing this form, I acknowledge and understand the information will be given to me and I am aware that I can clarify any aspect of my consent at any time. This consent will be reviewed annually or at any time at my request. I acknowledge that staff working with me and others who are involved in my plan or programme may need to share health information to ensure I receive a quality service. I acknowledge that staff will only share my information with other services, as necessary. *