Client Intake Form

A FINANCIALLY LITERATE COMMUNITY THAT HAS ITS CONSUMER RIGHTS

Financial Mentoring and Privacy Authorisation

Address Office: A: Unit 6/ 6 Rocklands Ave, Balmoral

This page grants permission for your Financial Mentor to speak to organisations about your finances, and sets out the responsibilities of the client, financial mentor and service.

E: info@aucklandbudgeting.org.nz

Full Name

Name

First NameLast Name

Address

Date of Birth

Ethnicity

Email

example@example.com

Phone

Client Waiver Inaccordance with the Privacy Act 2020, I understand this information is to be recorded. My file my also be viewed by a representative of our contract provider, the Ministry of Social Development, during our annual audit.

Iunderstand the service and/or financial mentor is not liable to me under any circumstances for their actions or any advice they give, however that liability arises (including through negligence I authorise organisations to share my financial information with my Financial Mentor on request so they can provide me with appropriate financial capability and financial mentoring advice. Iauthorise my Financial Mentor to access on my behalf my credit information held with credit reporting agencies and the credit reporting agency to disclose my credit information. Iauthorise my Financial Mentor to share my information with appropriate parties. I intend this authorisation satisfies the requirements of the Privacy Act 2020.

Client Signature

Clear

Date Signed

This agreement expires 12 months form signed date or earlier on

We will keep all client details confidential, except as authorised in this agreement. We will keep the client informed of matters relating to the clients finances. We have verified the clients identity by looking at their drivers licence of another form of photo ID

Service Name: Auckland Central Budgeting Consultants Inc.

Verification of Clients Identity

PERSONAL INFORMATION