Declared at this day of 20
(person before whom the declaration is made)
AddressSignature of Witness
• I have read the privacy statement in section 6 of this ASB KiwiSaver
Scheme First or Previous Home Owner Withdrawal Application Form.
• I have not made a withdrawal from a KiwiSaver scheme (whether the
ASB KiwiSaver Scheme or any scheme to which I have previously
belonged) for a ﬁrst or previous home owner withdrawal before.
• The land or property I am purchasing is an estate in land or an interest
in a dwellinghouse on Maori land located in New Zealand and is or is
intended to be my main residence.
• I have not held an estate in land before (whether alone or as a joint
tenant or a tenant in common) or if this is not the case, I attach
conﬁrmation from the Minister of Housing (or his delegate) that my
income, assets and liabilities represent a ﬁnancial position that would
be expected of a person who has never held an estate in land.
• I understand that, should the information given be incomplete or
incorrect, the Manager of the ASB KiwiSaver Scheme will not be able
to complete its assessment of the application for my ﬁrst or previous
home owner withdrawal without receiving the complete and correct
• I understand that ﬁnal approval of my application for a ﬁrst or
previous home owner withdrawal is subject to the Manager receiving
(in a form acceptable to the Manager) at least ten working days prior
to the date that your solicitor or conveyancing practitioner needs to
receive my KiwiSaver savings (either to pay a deposit or to pay to the
vendor on settlement day):
i. a pre-printed bank deposit slip for my solicitor's or conveyancing
practitioner's trust account; and
ii. a certiﬁcate from my solicitor or conveyancing practitioner
attaching a copy of the Sale and Purchase Agreement which
clearly shows me as the purchaser and contains undertakings (in
a form acceptable to the Manager) relating to the status of that
Agreement and the application of savings withdrawn; and
iii. for an interest in a dwellinghouse on Maori land, evidence of my
right to occupy the Maori land; and
• I understand that my ﬁrst or previous home owner withdrawal is
subject to the approval of the Manager.
• I understand that my withdrawal value will be based upon the unit
price(s) at the date my request is processed.
• I agree that any solicitor or conveyancing practitioner who has or
will provide information about my ﬁrst or previous home owner
withdrawal may be approached by the Manager, and I hereby
authorise such solicitor or conveyancing practitioner to give such
further information in relation to this purchase as requested by the
Manager. A photocopy of this authorisation shall be read as the
• I expressly consent to the Manager disclosing my ASB KiwiSaver
Scheme contribution history to K¯ainga Ora, provided such disclosure
is necessary for K¯ainga Ora to determine whether I may be eligible for
other assistance or services provided by K¯ainga Ora.
• The information provided by me is true and correct.
And I make this solemn declaration conscientiously believing the same to
be true and by virtue of the Oaths and Declarations Act 1957.
(insert name of person making the declaration)
(insert address and occupation of person making the declaration
solemnly and sincerely declare that:
FOR BANK USE ONLY
Method of identification - Customer
A Statutory Declaration under the Oaths and Declarations Act 1957 that is made in New Zealand must be made before a person described in
section 9 of that Act including:
• a justice of the peace; or
• a barrister or solicitor of the High Court; or
• a notary public; or
• the Registrar or Deputy Registrar of the High Court or of any
District Court; or
• a member of Parliament; or
• officers of the Crown or of a local authority within the meaning of
the Local Government Act 2002, authorised for that purpose by the
Minister of Justice from time to time; or
• an employee of Public Trust constituted under the Public Trust Act
2001, authorised for that purpose by the Minister of Justice from
time to time.
ASB Group Investments Limited 56520 12527A 0820
Signature of person making the declaration
• While I have been a KiwiSaver member (please tick one):
New Zealand has been my principal place of residence at all times; or
New Zealand has been my principal place of residence for
the following period(s):
DD/MM/YYYY - DD/MM/YYYY
DD/MM/YYYY - DD/MM/YYYY
ASB KiwiSaver Scheme
New Zealand Statutory Declaration