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.

6. New Zealand Residency

4. Gross Income - Per annum

a) Social Welfare Benefit

$ 0

Type

Are you a New Zealand Citizen:

b) Salary/Wages

$ 437

If no, are you permitted to reside in New Zealand permanently:

c) Total

$ 437
437

Please supply a certificate of earnings from your

employer

5. Assets and Liabilities (for all applicants)

a) Do any applicants currently own or have a financial
interest in any house, flat or other property in New
Zealand or overseas?

Yes (tick in box)

No (tick in box)

If yes, Address of Property:

Value of applicants 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, but are allowed to reside in New Zealand permanently, please bring
your immigration documents with you when you come in for an interview.

7. 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. A criminal charge is one in which it is
alleged that you have broken the law in some way.
(We do not include traffic offences other than drink driving or convictions that are subject to the Criminal
Records (Clean Slate) Act 2004.) 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.

8. General Practitioner
Name:

If yes, Address of Property:

Practice:

9. 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.g.

Presbyterian Support, CCS, District Psychiatric Nurse
If yes, 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

$ 341.85

Name:

Agency:

03 0915 0393228 00

$ 15 (Approx)

Bank Account / Investment

Other Assets (excluding personal effects and furniture):

10. 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, please list:

Telephone:
Relationship:

e.g. son, daughter, friend etc

6. New Zealand Residency

4. Gross Income - Per annum

a) Social Welfare Benefit

Type

Are you a New Zealand Citizen:

b) Salary/Wages

If no, are you permitted to reside in New Zealand permanently:

c) Total

Please supply a certificate of earnings from your

employer

5. Assets and Liabilities (for all applicants)

a) Do any applicants currently own or have a financial
interest in any house, flat or other property in New
Zealand or overseas?

Yes (tick in box)

No (tick in box)

If yes, Address of Property:

Value of applicants 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, but are allowed to reside in New Zealand permanently, please bring
your immigration documents with you when you come in for an interview.

7. 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. A criminal charge is one in which it is
alleged that you have broken the law in some way.
(We do not include traffic offences other than drink driving or convictions that are subject to the Criminal
Records (Clean Slate) Act 2004.) 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.

8. General Practitioner

If yes, Address of Property:

Name:

Dr Raghupati

Practice:

Community Support, Dunedin

9. 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.g.

Presbyterian Support, CCS, District Psychiatric Nurse
If yes, 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. 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, please list:

Telephone:
Relationship:

0204077700

Friend

e.g. son, daughter, friend etc

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)
of (full address)

1. 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, 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

Contact Phone No:

2. 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.

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