Tenancy
INSULATION STATEMENT
Landlords must either complete this form or attach a signed insulation statement containing the same information.
Address of tenancy:
1. Does insulation meet the minimum requirements for ceiling insulation?
1
Yes No
If no, explain what exception applies and which room(s) it applies to (e.g. professional installer cannot access skillion ceiling
above bedroom 2).
2. Does insulation meet the minimum requirements for underfloor insulation?
Yes No
If no, explain what exception applies and which room(s) it applies to (e.g. professional installer cannot access subfloor space
safely).
Ceiling insulation
Location/coverage
Complete (all rooms)
Partial (specify areas not insulated):
None
I don’t know as ceiling space is not accessible in the following areas (specify):
Type
Segments/Blankets
Loose-fill
Other (specify)
Ceiling space is not accessible
Bulk Insulation value (R-value):
or minimum thickness:
Age of ceiling insulation (if known):
Condition Insulation is in at least a reasonable condition (if not, please explain why):
Insulation has no gaps other than clearances where required (e.g. around older style downlights and
chimneyflues)
Ceiling space is not accessible
Underfloor insulation
Location/coverage
Complete (all rooms)
Partial (specify areas not insulated):
None
I don’t know as underfloor space is not accessible
inthe following areas (specify):
RTA Residential Tenancy Agreement
www.tenancy.govt.nz LANDLORD’S COPY = TOP COPY TENANT’S COPY = BOTTOM COPY
PAGE 
The Building Act 2004 bans the installation
and/or repair of foil insulation in residential
buildings with existing electrical installations.
Anyone doing so may be liable to a fine of up to
$200,000. Foil insulation which is in
reasonable condition does not need to be
replaced. Existing foil installation which is
damaged (e.g. torn, foil hanging down off the
floor joists or is no longer reflective), must be
replaced with insulation which meets legal
requirements.
1
For guidence on exceptions and requirements, refer to MBIE’s Insulation Requirements - A guide for Landlords: www.tenancy.govt.nz/assets/Uploads/
Insulation-requirements.pdf
Tenancy
Type Segments/Blankets
Polystyrene
Foil
Bulk Insulation with foil lining
Other (specify)
Underfloor space is not accessible
Bulk Insulation value (R-value):
or minimum thickness (n/a for foil):
Age of underfloor insulation (if known):
Condition Insulation is in at least a reasonable condition (if not, please explain why):
Insulation has no gaps other than clearances where required (e.g. around pipes)
Underfloor space is not accessible
Wall insulation
Location/coverage
Complete (all rooms)
Partial (specify areas not insulated):
None
I don’t know as wall insulation is not accessible
Supplementary
Information
Any other details about the type or condition if known:
Date insulation was last upgraded
or N/A 
Date insulation was professionally assessed or N/A 
Landlord Statement
I/we, (name of landlord(s)) declare
thatthe information contained in this insulation statement is true and correct as at the date of signing and that all reasonable
efforts have been made to obtain information about the location, type and condition of insulation at the premises.
Signed by Date signed
LANDLORD
Healthy Homes Standards Statement
Strike out one option
I/we,
(name of the landlord(s)) will
comply with the healthy homes standards as required by section 45(1)(bb) of the Residential Tenancies Act.
Signed by Date signed
I/we,
(name of the landlord(s)) already
comply with the healthy homes standards as required by section 45(1)(bb) of the Residential Tenancies Act.
Signed by Date signed
RTA Residential Tenancy Agreement
www.tenancy.govt.nz LANDLORD’S COPY = TOP COPY TENANT’S COPY = BOTTOM COPY
PAGE 2
Wall insulation is not compulsory.
However, you must provide this
information where it is known.
TENS 4700
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