2026 Wellbeing 60+ Health Grant Application Form

2026 Wellbeing 60+ Health Grant Application Form

Office Use
Type of Grant
Grant Status
Reason for Decline
Trustee Meeting Date

DayMonthYear
Date
Date Paid

DayMonthYear
Date
Amount Approved
2026 Wellbeing Health Grant Application
HAVE YOU ATTACHED YOUR 2026 RECEIPTS?

1. Please make sure your receipts are clear and visible for processing.

2. Receipts must total $300.00 or more.

3. If you are submitting doctor's visits, and prescriptions 2025 dates will not be processed.

4. Eftpos receipts must be accompanied with an invoice from the provider with your name and amount as confirmation of purchase.
Document Checklist
Do you have this information?*

OMR2 Information
Who is the owner/beneficiary*
Whanau Trust Name*
Shareholder Name*
Your BE Allocated Number*
Kaumatua Details
Name*

First NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Current Date

DayMonthYear
Age
Phone Number*

Area CodePhone Number
Email*
Please enter an email address to receive a confirmation of your application
Has your address changed?*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Has your bank details changed*
Bank Account Details

Please make sure you have the correct bank details.
Your Account Name*
Bank Account Number*
Please make sure you enter your bank account correctly to avoid delays in payment.

Upload bank verification*

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Grant Purpose
Grant Purpose*
Briefly explain you grant purpose

Total Cost*
Your grant amount must total more than $300.00
Upload Document*

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Declaration
Kaumatua Name*

First NameLast Name
Date Signed*

DayMonthYear
Should be Empty: