Village
Name of village: [insert name].
Registration number of village: [insert registration number].
Street address of village: [insert street address].
Address of registered office of village: [insert address, which must be a physical address in New Zealand and must not be a post office box or private bag address].
Address for service of village: [insert address, which must be a physical address in New Zealand and must not be a post office box or private bag address].
Postal address of village: [insert postal address].
Email address for village: [insert email address].
Telephone number for village: [insert telephone number].
Fax number for village (optional): [insert fax number, if desired].
Operator
Name of operator: [insert name of each operator of the village].
Company or other registration number (if any): [insert registration number for each operator of the village].
New Zealand Business Number (if any): [insert New Zealand Business Number of each operator of the village].
Nature of operator: [describe the nature of each operator of the village, eg, company, natural person].
Address of registered office of operator: [for each operator of the village, insert address, which must be a physical address in New Zealand and must not be a post office box or private bag address].
Address for service of operator: [for each operator of the village, insert address, which must be a physical address in New Zealand and must not be a post office box or private bag address].
Postal address of operator to which communications from the Registrar may be sent: [insert address for each operator of the village].
Email address of operator: [insert email address for each operator of the village].
Telephone number of operator: [insert telephone number for each operator of the village].
Fax number of operator (optional): [insert fax number for each operator of the village, if desired].
Certificate of registered documents
This is to confirm that each registered document for [insert name of the village] is correct, current, and not likely to mislead or deceive any resident, intending resident, or the public.
Date and signature
Signed: [insert signature for each operator of the village].
Name of operator: [insert name of each operator of the village].
Person completing form
Name of person completing form: [insert name].
Address of person completing form: [insert address].
Email address of person completing form: [insert email address].
Telephone number of person completing form: [insert telephone number].
Fax number of person completing form (optional): [insert fax number, if desired].
This form must be accompanied by all of the things required by section 13(3)(b) to (d) of the Retirement Villages Act 2003.
Schedule 1 form 2: amended, on 1 October 2019, by regulation 5(2) of the Retirement Villages (General) Amendment Regulations 2019 (LI 2019/166).