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APPLICATION TO REGISTER LAND AS A WHANAU - HAPU

[ I Nancy Tippet], of [ Native Title Maraeroa Hurakira Block CT Known as Lot 39 DP 55941 Ocean Veiw Cresent Rakino Island ], solemnly and sincerely declare:
THAT [I am] the registered [proprietor] of [the full official description of land, including the area and title or index book reference; also the street or general locality in which the land is situated] (and of the following relative shares, namely, [ 6=specify particulars]).
THAT [9=my wife and I  OR  my husband and I  OR  we] at present (or will within six months of the date hereof be) reside and have our home in a [10=dwellinghouse  OR  flat] erected on the said land.
THAT the said [10=dwellinghouse  OR  flat] and land are (or will within six months of the date hereof be) used exclusively as a home for [11=my wife and me  OR  my husband and me  OR  us] and the following members of our household, namely [12=state names and relationship]<Option 2 (in or out)=, except to this extent, namely:  [13=state other uses to which they are being put]>.
THAT [3=I am  OR  we are] able at the date hereof to pay all [14=my  OR  our] debts other than debts charged on the property that is being settled without the aid of that property.
THAT [15=I am not and my wife is not  OR  I am not and my husband is not  OR  neither of us is] the owner, or a joint owner, of any other joint family home registered as such under the provisions of the Joint Family Homes Act 1964<Option 3 (in or out)=; and that we [16=have  OR  have not] previously been the joint tenants under that Act of a joint family home at [17=address of joint family home]>.
THAT the [18=place  OR  several places] where [19=I  OR  we] have during the 12 months preceding the date hereof resided, or carried on business, are as follows:  [20=specify place or places and period].
THAT [19=I  OR  we] have no creditors who reside in any other place.
THAT [14=my  OR  our] address for service is [21=address for service].
AND [19=I  OR  we] hereby apply to register the said land as a joint family home under the provisions of the Joint Family Homes Act 1964.
AND [19=I  OR  we] make this solemn declaration conscientiously believing the same to be true under and by virtue of the Oaths and Declarations Act 1957.

DECLARED at [22=place where document signed] this      day of      [year] before me:

[23=Justice of the Peace  OR  A Solicitor of the High Court of New Zealand]