housing application form · full central heating gas fires no heating part central heating electric...
TRANSCRIPT
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APPLICANT
Full name
Current address
Postcode
Housing Application Form
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CHISLEHURST & SIDCUP HOUSING ASSOCIATION HOUSING (CSHA) APPLICATION FORM
You must complete ALL sections of this form
Please answer in the boxes provided, by writing clearly or ticking where appropriate
1. Name and address - couples or two adults should fill in both sections
APPLICANT PARTNER/JOINT APPLICANT
Title (Mr/Mrs/Ms/Miss)
Surname
First name(s)
Date of birth
National Insurance Number
Present address
Postcode
Home telephone number
Work telephone number
Mobile number
Email address
Do you or your partner/joint applicant have any mental or physical disabilities
APPLICANT PARTNER/JOINT APPLICANT
Mental disability Yes No Yes No
If Yes, please specify
Physical disability Yes No Yes No
If Yes, please specify
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2. Please give details of your Next of Kin (other than Partner/Joint Applicant)
APPLICANT JOINT APPLICANT/PARTNER
Name
Relationship to you
Home/Work number(s)
Mobile number
Email address
3. Reason for housing—please tick the main reason you wish to be rehoused
Home too large/too small Asked to leave by family or friends
Home in need of major repairs To take up work
Health reasons Local connection
To give or receive care Homeless
Suffering violence or harassment Member of the Armed Forces
Subject to Immigration Controls Other
If any of the above are ticked, please specify and give any other information that you feel explains
why you wish to be rehoused
If you have been asked to leave your present home, please give details below and include the date
you will have to leave together with copies of any legal notices or letters from family/friends
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4. Please give details of your present accommodation
ALL QUESTIONS TO BE COMPLETED
Type of property:
Flat/Maisonette House Bed & Breakfast
Bedsit Bungalow Hostel/Refuge
Other (please specify)
On which floor do you live?
Ground First Second Third
Yes No Is there a lift?
Total no. of bedrooms in property Double Single No. of bedrooms you use
Owner/occupier? Tenant? Are you or your partner
Lodger? In tied accommodation? Other (please specify)
If you own a home, amount of equity £
If property has been owned we need proof of equity. If the property is still for sale, this is a copy
of the estate agent valuation and mortgage statement. If property is sold, this is a copy of the
completion statement.
We cannot accept applications from anyone with savings or equity in excess of £50,000.
Who else lives in the property but will not live with you when you move?
First name(s) Surname Gender (M or F) Relationship to you Date of birth
Years Months How long have you lived at your present address?
Yes No Do you own, or have a tenancy of any other residential property?
If you are a tenant, name and address of landlord of Applicant
Landlord
Address
Postcode Contact Number (s)
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Years Months How long have you lived at your present address?
Yes No Do you own, or have a tenancy of any other residential property?
Name and address of landlord of Partner/Joint Applicant
Landlord
Address
Postcode
Do you share bathroom or kitchen facilities with people who are not family or friends?
Please give details:
How is your home heated? Full central heating Gas fires No heating
Part central heating Electric or open fires
If your home is in need of major repairs (e.g. rewiring, roof repairs) please give details
Yes No Has an Environmental Health Officer visited your address?
If yes, please enclose a copy of the report.
Yes No Do you currently have rent arrears?
If yes, please specify
Yes No Do you have a record of antisocial behaviour?
If yes, please specify
Yes No Do you have any unspent criminal convictions?
If yes, please specify
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5. Previous addresses - please give details of all the addresses where you and your
partner have lived over the past 5 years
Applicant
Date from Address
Date to Postcode
Reason left
Was the property rented/owned with family or friends (please delete)
If rented name and address of landlord
If the property has been sold, please include a copy of the completion statement
Applicant
Date from Address
Date to Postcode
Reason left
Was the property rented/owned with family or friends (please delete)
If rented name and address of landlord
If the property has been sold, please include a copy of the completion statement
Partner/Joint Applicant
Date from Address
Date to Postcode
Reason left
Was the property rented/owned with family or friends (please delete)
If rented name and address of landlord
If the property has been sold, please include a copy of the completion statement
Partner/Joint Applicant
Date from Address
Date to Postcode
Reason left
Was the property rented/owned with family or friends (please delete)
If rented name and address of landlord
If the property has been sold, please include a copy of the completion statement
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6. Details of accommodation you require
Please list the scheme areas where you would prefer to live (in order of preference)
1. 2.
3. 4.
How many bedrooms do you need?
Yes No Do you need ground floor accommodation?
Would you prefer accommodation where there is a full-time
Sheltered Housing Manager? Yes No
Please give details of any special facilities required for any person with disabilities
Please give details if you or any member of your family cannot return to live in the home due
to ill health or disability (e.g. where the hospital will not discharge the patient due to the current
home being unsuitable)
Please give details if anyone to be rehoused cannot use part of his/her present home (e.g.
cannot climb stairs)
Please give details if the health of anyone to be rehoused is made worse by his/her present
home or location
If you have any other information relating to your health or disability that will help us to deal
with your application please give details on a separate sheet. Please enclose a letter from
your doctor to support your application.
Do you have private vehicles? Yes No If yes, how many?
PLEASE NOTE THAT NO PETS ARE ALLOWED IN OUR SHELTERED ACCOMMODATION
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Current job
Name of employer
Address of employer
Postcode
Take home pay (£ per week)
In which Borough do you work
How long have you been with your current employer
7. Income details (we are asked to provide the Government with financial information
covering all new lets)
Income from work
APPLICANT
Current job
Name of employer
Address of employer
Postcode
Take home pay (£ per week)
In which Borough do you work
How long have you been with your current employer
PARTNER/JOINT APPLICANT
APPLICANT Yes Amount
No
Attendance Allowance £
Disability Living Allowance (DLA) £
Employment and Support Allowance (ESA) £
Incapacity Benefit £
Income Support £
Personal Independence Payment (PIP) £
Other State Benefits (please specify) £
Benefits - please tick all that apply and enter amount for each:
Job Seeker’s Allowance (JSA) £
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State Pension £
Workplace Pension £
Other Pension (please specify) £
Savings & Investments (please give details) £
£
Benefits - continued:
APPLICANT Yes Amount
No
State Pension £
Workplace Pension £
Other Pension (please specify) £
Savings & Investments (please give details) £
£
8. Relationship to employees or Board Members of Chislehurst & Sidcup HA
Yes No Are you or your partner/joint applicant employed by CSHA?
Are you or your partner/joint applicant related to a Member of the Board or an
employee of CSHA? Yes No
If yes, please give details:
9. Rejection and Exclusion Policy
The use of violence or the threat of violence against any tenant, employee, Board Member, or
Agent of Chislehurst & Sidcup HA, or anyone else lawfully on the scheme? Yes No
Harassment of others, as listed immediately above? Yes No
Does one or more of the criteria listed below apply, or has it applied during the last 6 years, to you
and/or to members of your household?
PARTNER/JOINT APPLICANT Yes Amount
No
Attendance Allowance £
Disability Living Allowance (DLA) £
Employment and Support Allowance (ESA) £
Incapacity Benefit £
Income Support £
Personal Independence Payment (PIP) £
Other State Benefits (please specify) £
Job Seeker’s Allowance (JSA) £
Benefits - please tick all that apply and enter amount for each:
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Causing wilful damage to property? Yes No
Arson? Yes No
Forfeiture of a probationary tenancy? Yes No
A history of anti-social behaviour? Yes No
A record of repetitive car crime, burglary or other criminal damage? Yes No
A history of drug related offences? Yes No
A record of offences against children? Yes No
A record of other criminal offences that have a relation to community matters? Yes No
A conviction for a criminal offence, other than a spent conviction under the
Rehabilitation of Offenders Act 1974? Yes No
If yes, please give details below including date of offence plus name and address of probation officer
10. Communication
What is your first spoken language?
What is the main language you read?
Are you happy with this form and the information we have provided to you? Yes No
If no, how would you like us to communicate with you? (Please tick below)
Large print Translation/other language Cassette/tape Braille
Other (please comment)
Family & Friends Newspaper Council/Housing Association
IT/Web Site Local Advertising Other
Where did you find out about Chislehurst & Sidcup HA? (Please tick below)
11. Please provide the contact details for your GP
APPLICANT PARTNER/JOINT APPLICANT
Doctors name
Address
Contact Number
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I/we have made an application for housing with:- Chislehurst & Sidcup HA
I/we understand that Chislehurst & Sidcup HA will need to carry out enquiries concerning my/our
character and conduct of any previous tenancies or occupations of any property in the past
I/we give my/our permission and consent for Chislehurst & Sidcup HA to obtain any relevant
information about me/us from all relevant agencies. I/we understand that the relevant agencies
may include, but are not limited to, any police force, previous landlords, Probation Service, Social
Services and Education Departments of local authorities
I/we give my/our permission for Chislehurst & Sidcup HA to seek medical information in connection
with this application and a fee may be payable
I/we understand that this information will be used for the sole purpose of assisting my/our housing
application, and will be held in the strictest confidence. This includes information protected by the
Data Protection Act 1998.
Both applicants must sign if the application is a joint one
Signed (Applicant) Date
PRINT NAME
Signed (Partner/Joint Applicant) Date
PRINT NAME
Please ensure all sections of this form are completed. Partially completed forms will not be
accepted
Both applicants must sign if the application is joint
Signed (Applicant) Date
Signed (Partner/Joint Applicant) Date
13. Statement
I confirm that I have completed the Informed Consent Section of this application form. I
confirm that the details given in this application are true. I understand that if I have knowingly
or recklessly given any false information, or withheld information in connection with this
application, my accommodation may be repossessed by virtue of Schedule 2 of the Housing
Act 1985 (as amended)
12. Informed Consent
APPLICANT PARTNER/JOINT APPLICANT
Full name
Current address
Date of birth
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14. Equality and Diversity
Your application will not be treated differently because of your colour, ethnic or national origin,
nationality, gender, sexual orientation, marital status, physical or learning disability, age or religion.
Choose one option that best describes your ethnic group or background:
Please return this completed form to:
Asian/Asian British – Bangladeshi Black - Any Other Background White - British
Asian/Asian British – Indian Chinese White - Gypsy or Irish Traveller
Asian/Asian British – Pakistani Mixed/White & Asian White - Irish
Asian – Any Other Background Mixed/White & Black African White - Any Other Background
Black/Black British – African Mixed/White & Black Caribbean Other Ethnic Group - Arab
Black/Black British – Caribbean Mixed - Any Other Background Other Ethnic Group - Any Other
Chislehurst & Sidcup Housing Association
45 Invicta Close
Chislehurst
Kent
BR7 6SJ
FOR OFFICE USE ONLY
Application No.