Queen Street, P O Box 404, Te Kuiti 3941, NZ. Telephone 07-878 0800, Fax 07-878 7771, Email email@example.com, Website www.waitomo.govt.nz
I/We solemnly and sincerely declare that:
1. I/We am/are the owner(s)/occupier(s) of the property situated at:
2. I/We hereby declare that the dwelling house situated on the above property is uninhabitable and
is not and will not be used as dwelling now or in the future.
3. I/We hereby agree that the rating information held about this property be amended if required.
For the avoidance of doubt, an uninhabitable dwelling is classied as such when it is not connected to water
or sewerage services, has no kitchen facilities (including a means of cooking) available. The dwelling must
be in a derelict state and unable to be used in any way. There is also no intention to restore the dwelling
in the future.
Note: A Statutory Declaration must be made by 31 May to be effective for the rating year
beginning 1 July.
And I/we make this solemn declaration conscientiously believing the same to be true and by virtue of the
Oaths and Declarations Act 1957.
Dated: This day of 20
Name (please print):
Justice of the Peace:
Ofce Use Only:
Correction of RID and DVR
Ratepayer notied of decision.
For dwellings that are uninhabitable and should be
removed from the Rating Information Database