Title Page

  • Landowner

  • Job Number

NGĀ PUNA RAU RANGITĪKEI Freshwater Grant Claim Form

  • Type of Claim Form

  • Environmental Management Officer

  • Job Number

Claimant Details

  • Name of Claimant

  • Postal Address
  • Telephone Number

  • Cell Phone Number

  • Email Address

Completed Works

  • Financial Year Works Completed

  • Fencing

  • Type of Fencing

  • Length of Fencing

  • Rate/m ($)

  • More Fencing

  • Type of Fencing

  • Length of Fencing

  • Rate/m ($)

  • Total Fencing Cost (excl. GST)

  • Plants

  • Number of Plants Planted

  • Supplier of plants

  • Cost of Plants ($)

  • More than one supplier of plants

  • Number of plants planted

  • Supplier of Plant

  • Cost of Plants

  • Total Cost for Planting ($)

  • Total Plant Costs (excl. GST)

  • Other

  • Other Costs

  • Total Other Costs (excl. GST)

Funding Share of Costs

  • Funding share of fencing costs (TMORT/HRC/Landowner) ($)

  • Funding share of planting costs (TMORT/HRC/Landowner) ($)

  • Funding share of other costs (TMORT/HRC/Landowner) ($)

  • Percentage share of fencing costs (TMORT/HRC/Landowner) (%)

  • Percentage share of planting costs (TMORT/HRC/Landowner) (%)

  • Percentage share of other costs (TMORT/HRC/Landowner) (%)

  • Total cost share (TMORT/HRC/Landowner) ($)

  • Average percentage (TMORT/HRC/Landowner) (%)

  • Purchase order number

Location of Works

  • Location of Works
  • Water Management Zone

  • Map and photo of completed works

Risk Management

  • Were there any incidences (injury, illness, near miss) when undertaking the work?

  • What incidences occurred?

  • Were any new risks identified or any changes to controls needed for existing risks?

  • What risks/ changes were identified?

  • Is there anything new we have learned that will improve safety for future projects?

  • What have we learned?

Certification

  • 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.

  • Signature of Claimant

  • 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.

  • Signature of Environmental Management Officer

  • Signature of NPRR Project Manager/Executive

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