Heritage Protection Fund - Claim Form

Recipients are required to present receipts for the work done and a statement confirming that the work has been carried out according to the information provided in the application. This must be done prior to the payment of the grant.
Unless a prior arrangement for an extension is made, which should be put in writing, this documentation should be submitted within one year of the grant's acceptance.

This form must be completed in one session.

Please ensure you have all necessary information and documentation ready before you begin.

If you encounter any issues with the application form, please contact funding@selwyn.govt.nz.

Privacy Notice - Personal information collected through this form will be used to assess your grant application and will be handled and held in accordance with the Privacy Act 2020 and Selwyn District Council's Privacy Policy [PDF, 6494 KB]

Applicant Details:

Full Name: *

Postal Address: *

Phone Number: *

Email Address: *

Heritage Item Details

Name of building, site or tree for which assistance was received: *

Physical Location of building, site or tree: *

Is the building, site or tree listed in the Selwyn District Plan? *

If yes, please provide the Reference:

Is the building, site or tree registered by the New Zealand Historic Places Trust? *

If yes, please provide the Category:

Project Details

Details of the work completed: *

Grant Details

Did you spend the grant for the purpose stated in your application? *

If the funds were not used for the intended purpose stated in your application, please explain the reasons and describe how the funds were spent:

Amount of grant awarded: *

Date grant awarded: *

Amount of grant being claimed: *

Supporting Documents

Receipts for work completed: *

Photos of work completed: *

Additional documents or receipts to support your claim: Optional

Bank Account Details

Name on Bank Account: *

Bank Account Number: *

Postal Address: * For bank account

Email Address: * For remittance

If you're registered for GST, please provide your GST number here:

Please upload proof of bank account: * any one of these: a deposit slip, a letter from the bank, or a bank statement showing the account number

Declaration

Privacy Notice Personal information collected through this application will be handled in accordance with the Privacy Act 2020 and Selwyn District Council’s Privacy Policy.

I declare that the above information is true and correct *

I agree

Privacy statement

The personal information you provide in this form will be collected, held and protected by Selwyn District Council in accordance with our Privacy Policy and the Privacy Act 2020. Our Privacy Policy explains how we use and share personal information in relation to any interaction you have with Council, and how you can access or correct your information at any time.

You can read the full policy at selwyn.govt.nz/privacy.

We will use the email address you provide to send communications directly related to this form or application. By submitting this form, you consent to receive those communications by email. If you require a hard copy, please email ContactUs@selwyn.govt.nz, visit our Service Desk Team or call 0800 SELWYN (735 996).

Heritage Protection Fund - Claim Form

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