Office Use
Grant Status
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Complete
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Approved
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Type of Grant
Please select
Dental
GP Visits & Prescriptions
Hearing
Vision
Other Purposes
Amount Approved
Reason for Decline
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Trustee Meeting Date
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Day
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Month
Year
Date
Date Paid
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Day
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Month
Year
Date
DOCUMENT CHECKLIST
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OMR2 Information
Who is the owner/beneficiary
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I am a Beneficiary of a Whanau Trust
I am a Beneficiary of an Individual Owner
I am the Owner
Whanau Trust Name
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Shareholder Name
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Kaumatua Details
Name
First Name
Last Name
Your BE Number
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Date of Birth
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Day
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Month
Year
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Current Date
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Day
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Year
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Age
Email
example@example.com
Phone Number
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Area Code
Phone Number
Has your address changed?
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Yes
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have your bank details changed
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Yes
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Bank Account Details
Please make sure you have the correct bank details.
Your Account Name
*
Bank Account Number
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Please make sure you enter your bank account correctly to avoid delays in payment.
Upload bank verification
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Grant Purpose
Main Grant Purpose
*
Please select
Dental
GP visits & prescriptions
Hearing
Vision
Other purposes
Briefly explain grant purpose
*
Total Cost
*
Enter the amount of the total cost. e.g $450
Upload Tax Invoice and receipt of payment
*
Browse to your files to upload a copy of 2023 tax invoice or receipt of payment to verify your purchase(s).
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Declaration
Kaumatua Name
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First Name
Last Name
Date Signed
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