Kaumātua Grant Apply | Aotearoa Trust

Kaumātua Grant Application Form

"*" indicates required fields

Beneficial Owner’s Name*

First Name/s Last Name

Preferred Name

Beneficial Owner’s Shareholding Number

Beneficial Owner’s Address*

Street Address Address Line 2 Town/City Region Post Code Country

Home Phone

Mobile Phone

Email

IRD Number*

Date of Birth*

Proof of Age

Can you provide proof of age?*

Yes

No

Proof of Age*

Max. file size: 100 MB.

Please attach a copy of one of the following, either your birth certificate, drivers licence, passport, or Superannuation gold card.

Statutory Declaration

If proof of age can not be provided please download and complete the following Statutory Declaration alongside a Solicitor of the High Court of New Zealand or Justice of the Peace.

Download Declaration Form

Forms must be returned by 28 February. Upload your completed declaration form to the field below OR post it to The Secretary, Aotearoa Trust, Cleland Hancox Limited, P O Box 9495, Hamilton 3240

Upload Completed Declaration form

Max. file size: 100 MB.

Bank Account Details for Payment

Name on Bank Account*

Bank*

Branch*

Bank Account Number*

Proof of Account*

Max. file size: 100 MB.

Please attach an encoded deposit slip or a document from your bank certifying your bank account details.

Declaration*

I confirm that the above information is true and correct and that proof of my age is attached.

Beneficial Owner's Signature*

Date*

Comments

This field is for validation purposes and should be left unchanged.