Online Hardship Name Street Address Post Code Email Business Telephone Home Telephone Mobile Applicants date of birth Age Male/Female MaleFemale Ethnicity EuropeanMaoriAsianPacificMiddle EasternLatin AmericaAfricanOther Age (or range of ages) of children in your care? Describe exactly the assistance or item you require and how the items or grant are to be used To help us better access your application, please attach documentation to support your application e.g. quote, bills max. 2MB Please describe a little about your present circumstances - including any illness or disability that may be relevant to this application What difference will this grant or item make? Do you live in your own home renting property? OwnRent Mortgage/rent payments weekly What is your main source of income? What is your weekly surplus after deducting expenses? Have you applied to Kiwi Outreach before Yes No If yes, date and details Have you applied to any other source for this funding? Yes No If YES, please give details Do you have any convictions for fraud or dishonesty Yes No If YES, provide details Please read before submitting I believe the information to be true and correct. I understand that this information will be used by Kiwi Outreach to establish our need for a grant. Should our application be successful I/we accept Kiwi Outreach may, in its sole discretion, use any information relating to the application or the applicant for the purpose of publicity to raise awareness of Kiwi Outreach and the assistance that they provide and the applicant consents to such use. Your contact details will be put on our database to keep you up to date with Kiwi Outreach activities. If you do not wish to be contacted in the future, please advise us in writing. By clicking acceptance you agree to the above. Send