Home Owner Health Subsidy Application Form

The following application form is to apply for a Southland Warm Homes Trust health subsidy of $1000. For approval the following criteria must be met, I am the Home owner/occupier, I’m currently outside the current Warmer Kiwi Subsidy criteria. I live in decile 6&7 area (if unsure our team can check for you, just complete this form) and someone in the household has health issues. Well South will receive the application and assess the information to make a decision on the application. The application process can take 2-3 weeks. Once assessed you will receive notification of the outcome.
Please name all household members, their relationship to the applicant and any health issues.

Declaration

Once I submit this form (clicking the submit button below), I declare the above information is true and accurate to the best of my knowledge. I understand that if approved I will receive a Southland Warm Homes Trust $1000 subsidy towards my quote provided by Awarua Synergy. The home is “pledged” to be Smokefree: i.e. tobacco and other substances are not smoked by the occupants within the home and that if I acknowledged I do smoke, a referral to stop smoking will be sent. I give access to Well South to access my health records to check over this application.