Title Page
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Landowner
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Job Number
Freshwater Grant Claim Form
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Type of Claim Form
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Environmental Management Officer
- Lucy Ferguson
- Anna Regtien
- Anna Monk
- Claire Ridler
- Joe Martin
- Other
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Job Number
Claimant Details
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Name of Claimant
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Postal Address
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Telephone Number
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Cell Phone Number
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Email Address
Completed Works
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Financial Year Works Completed
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Fencing
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Type of Fencing
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Length of Fencing
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Rate/m ($)
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More Fencing
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Type of Fencing
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Length of Fencing
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Rate/m ($)
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Total Fencing Cost (excl. GST)
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Plants
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Number of Plants Planted
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Supplier of plants
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Cost of Plants ($)
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More than one supplier of plants
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Number of plants planted
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Supplier of Plant
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Cost of Plants
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Total Cost for Planting ($)
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Total Plant Costs (excl. GST)
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Other
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Other Costs
- Fenceline Prep
- Earthworks
- Fish Pass
- Structures
- Weed Control
- Troughs
- Gate
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Total Other Costs (excl. GST)
Total Costs
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Total Costs (excl. GST)
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Grant Rate (%)
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Total Grant (excl. GST)
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Purchase order number
Location of Works
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Location of Works
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Water Management Zone
- Mana_1a
- Mana_1b
- Mana_1c
- Mana_2a
- Mana_2b
- Mana_3
- Mana_4
- Mana_5a
- Mana_5b
- Mana_5c
- Mana_5d
- Mana_5e
- Mana_6
- Mana_7a
- Mana_7b
- Mana_7c
- Mana_7d
- Mana_7e
- Mana_8a
- Mana_8b
- Mana_8c
- Mana_8d
- Mana_9a
- Mana_9b
- Mana_9c
- Mana_9d
- Mana_9e
- Mana_10a
- Mana_10b
- Mana_10c
- Mana_10d
- Mana_10e
- Mana_11a
- Mana_11b
- Mana_11c
- Mana_11d
- Mana_11e
- Mana_11f
- Mana_12a
- Mana_12b
- Mana_12c
- Mana_12d
- Mana_12e
- Mana_13a
- Mana_13b
- Mana_13c
- Mana_13d
- Mana_13e
- Mana_13f
- Rang_1
- Rang_2
- Rang_3
- Rang_4
- Whai_1
- Whai_2
- Whai_3
- Whai_4
- Whai_5
- Whai_6
- Whai_7
- Whau_1
- Whau_2
- Whau_3
- Whau_4
- Tura_1
- Ohau_1
- Owha_1
- East_1
- Akit_1
- West_1
- West_2
- West_3
- West_4
- West_5
- West_6
- West_7
- West_8
- West_9
- Hoki_1
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Map and photo of completed works
Risk Management
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Were there any incidences (injury, illness, near miss) when undertaking the work?
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What incidences occurred?
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Were any new risks identified or any changes to controls needed for existing risks?
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What risks/ changes were identified?
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Is there anything new we have learned that will improve safety for future projects?
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What have we learned?
Certification
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I hereby certify that the above is a true and complete statement of costs (excluding GST) of work which has been carried out in a workman-like manner, in terms of Horizons Regional Council's approval, on my property, and hereby apply for a grant accordingly. Available for inspection are relevant invoices supporting the above purchases of Goods and Services.
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Signature of Claimant
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I hereby certify that I have inspected the work, and the work has been carried out in a satisfactory manner in accordance with the approved proposal and I now recommend payment of the Environmental Initiative Applicable.
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Signature of Environmental Management Officer
