APPLICATION FOR CEREDIGION HOUSING REGISTER

Transcription

1 Mid-Wales Housing Ltd Tai Canolbarth Cymru Cyf Tai Ceredigion Cyf Cyngor Sir CEREDIGION County Council Cymdeithas Tai Cantref APPLICATION FOR CEREDIGION HOUSING REGISTER BEFORE COMPLETING THIS FORM PLEASE READ THE ACCOMPANYING GUIDANCE NOTES If you do not complete the form fully, there may be a delay in registering your application whilst further details are sought. The attached leaflet explains more fully the points scheme and our procedures for registering your application. If you have any difficulty filling in this form, please ask a member of the Housing Register Team to help you. Please tell us if you need this document in large print In this form Ceredigion Housing Register means Ceredigion County Council, Mid Wales Housing, Tai Ceredigion and Cymdeithas Tai Cantref acting in partnership. FOR OFFICE USE ONLY Computer No. Cert. On Computer Acknowledged

2 Is this your first application? If no, from which address did you originally apply?. APPLICANT DETAILS JOINT APPLICANT DETAILS Mr. Mrs. Miss.... Surname..... First Names... Date of birth... National Insurance No.... Address Post Code :... Contact Telephone:... Mr. Mrs. Miss.... Surname..... First Names... Date of birth... National Insurance No.... Address Post Code :... Contact Telephone:... Status (please tick one of the following) SINGLE COUPLE FAMILY OTHER. PRESENT ACCOMMODATION Are you or your partner (Please tick appropriate box) Homeless In hospital, hostel, nursing home, foster home, children s home, supported lodgings Threatened with homelessness Prison Placed in Local Authority bed and breakfast/leased Accommodation Living with friends Living with a resident landlord Living in a house / flat shared with strangers

3 PRESENT ACCOMMODATION (CONTINUED) Living with parents/relatives Tenant of a Tai Ceredigion Property Tenant of other Local Authority property Tenant of a Cymdeithas Tai Cantref Property Tenant of a Mid Wales Housing Association property Tenant of other Housing Association property Shorthold tenant of house or flat If Yes you will also be considered for a mutual exchange If Yes you will also be considered for a mutual exchange If Yes you will also be considered for a mutual exchange If Yes you will also be considered for a mutual exchange If Yes you will also be considered for a mutual exchange Owner / Occupier In HM Forces or other tied accommodation If your accommodation is different from any of these, please give details:... Type of Current Dwelling No. of bedrooms in current property... (Tick as appropriate) No. of bedrooms used by your immediate family (immediate family means those persons who wish to be housed with you)... Flat Bungalow Bedsit House Ground Floor Caravan / Mobile Home First Floor Other (please specify) Second Floor EXTRA CARE SCHEMES s over 55yrs may request consideration for Extra Care Schemes operating in areas of their choice. Please tick reason(s) : May need future care Like on-site services e.g. café, hairdressers, shop Want to live independently but need support/care In residential care and want more independence 3

4 4. MEDICAL DETAILS If you wish any medical condition that you, or any person on this Application, suffer from to be taken into consideration please tick the box and a questionnaire will be sent to you. (In large print if required). Please indicate who in the household the forms are required for RESIDENCY Please give details of where you have lived in the last five years Address Type of Dates tenancy held From To Reason for leaving Address Type of Dates tenancy held From To Reason for leaving 6. PERSONS TO BE REHOUSED WITH THE APPLICANT Title Surname First Names Date of Birth Male / Female Relationship to applicant Tick if living apart Is anyone named above pregnant? If yes, when is the baby due? Please provide documentary evidence.... Do you have a child / children of a former marriage / partnership who stay with you regularly overnight? 4

5 PERSONS TO BE REHOUSED WITH THE APPLICANT (continued) Do you have legal access? (Please provide documentary evidence of access arrangements) If any person to be rehoused is living apart from the applicant give their address and the reason in the space below. Please list any person living with you at present who will not be re-housed with you 7. EQUALITIES INFORMATION GENDER Male Female (Please tick) ETHNICITY Male Female (Please tick) Our ethnic background describes how we think of ourselves. This may be based on many things, including, for example, our skin colour, language, culture, ancestry or family history. Ethnic background is not the same as nationality or country of birth. Please study the list below and tick one box only to indicate the ethnic back ground of the adult named above. This information will be collate and analysed to improve our work on planning services. WHITE CODE English Scottish Welsh Other white british Irish Traveller of Irish Heritage Gypsy/Roma WENG WSCO WWEL WOWB WIRI WIRT WROM ANY OTHER WHITE BACKGROUND Albanian Bosnian/Herzegovian Croatian Kosovan WALB WBOS WCRO WKOS 5

6 ANY OTHER WHITE BACKGROUND (continued) CODE Serbian Turkish/Turkish Cypriot Any other white background WSER WTUR WOTW MIXED/DUAL HERITAGE White and Black Caribbean White and Black African White and Asian Any other Other MWBC MWBA MWAS MOTH ASIAN OR ASIAN BRITISH Indian Pakistani Bangladeshi Sinhalese Sri Lankan Tamil Any other Asian Background AIND APKN ABAN ASNL ASLT AOTH BLACK Black British Black Caribbean Black Nigerian Black Ghanaian Black Somali Any other white background BLBR BCRB BNGN BGAN BSOM BOTH CHINESE OR ANY OTHER ETHNIC GROUP Chinese Afghanistani Arab other Filipino Iranian Iraqi Kurdish Lebanese OACH OAFG OARA OFIL OIER OIRQ OKRD OLEB ANY OTHER NOT ALREADY SPECIFIED 6

7 LANGUAGE(S) Language(s) spoken at home other than English or Welsh RELIGION None Christian Buddhist Hindu Muslim Sikh Jewish Any Other None Christian Buddhist Hindu Muslim Sikh Jewish Any Other 8. (a) INCOME DETAILS Income Joint Weekly Salary (net) Benefits Other Income e.g. :- Child Tax Credit Occupational Pension Total (Estimated) Net Weekly Household Income (b) SAVINGS as appropriate Under Between 3,000 Over 3,000 and 6,000 6,000 (c) CURRENT EMPLOYMENT CONNECTION WITHIN CEREDIGION APPLICANT Name of Employer Workplace Location Employment Commencement date JOINT APPLICANT Name of Employer Workplace Location Employment Commencement date 7

8 9. OWNER / OCCUPIER DETAILS Amount of mortgage outstanding Monthly repayments Value of property on open market.. Council Tax Band.... Are you able to maintain your mortgage repayments If no, evidence required from your mortgage advisor Please give details if any person on this application owns a property which has not been noted in this application RENT DETAILS OF PRESENT ACCOMODATION Date tenancy commenced Date Tenancy Ends... Weekly/monthly basic rent. Are you in Receipt of Housing Benefit / Local Housing Allowance? Is rent higher than Housing Benefit /Local Housing Allowance received? By how much?... If yes, please provide a copy of your Housing Benefit notification letter. Has your landlord asked you to leave? If yes, state why?... What type of tenancy do you have (this should be on your Tenancy Agreement) Name and address of your landlord

9 . FACILITIES IN YOUR PRESENT HOME Do you have the following facilities in your present accommodation? If so, are they used only by your immediate family or are they shared with others? (Immediate family means those persons who wish to be housed with you). Please Facilities Inadequate/lack of water supply Hot water supply Inside toilet Sink or wash hand basin Bath or shower Electricity supply Cooking facilities Garden Lack of heating Sole use by your immediate family Shared with relatives / others Not provided If your home is unsuitable for any other reason please give details below.... STATE OF REPAIR OF YOUR PRESENT HOME If the state of repair of your present home is causing you or your family problems please give details below. Please note that your landlord will be contacted to arrange a home visit to the property. We can also contact your landlord on your behalf, if you wish, regarding the need for repairs to your property PREVIOUS TENANCIES Have you or your partner ever held a tenancy of any Council or Housing Association dwelling? If yes please give the following details:- Tenancy Address... Landlord s Name and Address... Occupancy Dates... Reasons for leaving... 9

10 PREVIOUS TENANCIES (CONTINUED) Have you during the last five years, been convicted of a breach of tenancy agreement which occurred in a Council or Housing Association property? Or act(s) targeted towards staff, tenants or neighbours of a Council or Housing Association? If you have answered yes to the above two questions, then please provide details SUPPORT Does any person on this application, require to move, to give or receive essential support from relatives or friends? If YES, please provide documentary evidence and name and address of person receiving/giving support) a.. b.. c.... d.... Please complete the support needs questionnaire if you have answered YES to question PETS Do you require accommodation where you can keep a pet? Note: Some landlords do not permit pets to be kept in flats and restrict the number of dogs or cats to one per household in all its properties If you answered YES, please give details of pets.. 6. AREA REQUIRED Which area do you wish to live in? You can choose up to five areas IMPORTANT please study carefully the housing areas listed on the centre pages (which should be retained for your reference ). AREA AREA AREA AREA AREA

11 7. TYPE OF HOUSING REQUIRED Which type of housing would you wish to be considered for? Please indicate your choice below Bedsitter Tick Ground Floor Tick if necessary Flat Bungalow House First Floor Warden Controlled Extra Care Number of bedrooms required? WHY DO YOU WANT TO MOVE? Please indicate all reasons why you want to move Reason Please Reason Please Travel Problems Overcrowding Health / Medical Relationship breakdown Financial problems Bed and breakfast Need sheltered / warden support Requested to leave home Need wheelchair access Neighbourhood nuisance Harassment Poor housing conditions Need for independence Evicted Discharged from Institute/Hospital To be near family/friends Homeless Need for home with no external steps Any other reason please specify in Additional Information 9. AFFORDABLE HOUSING The council is promoting low cost home ownership which will assist local first time buyers, key workers, carers and other individuals and families with housing needs acquire a home of their own. If you are already living and working locally you may qualify and have priority for these homes. Would you wish to receive a Supplementary Housing Register Application Form? Would you be interested in the Council s assisted home ownership schemes and receiving further information on affordable homes in Ceredigion 0. In order to improve service delivery both Ceredigion County Council and Cymdeithas Tai Cantref wish to contact service users to obtain their views on the services we provide. Please indicate if you would be willing for us to contact you for your opinion at a later date?

12 . ADDITIONAL INFORMATION If there are any circumstances that you wish to have taken into consideration that have not been covered by any of the previous questions, please give details below. DECLARATION I/we declare that the information provided in this application is true and correct and that I/we shall notify the Ceredigion Housing Register of any changes in my/our circumstances (e.g. change of address, date of birth of baby etc). I/we agree to Ceredigion Housing Register making any enquiries that it feels necessary to clarify or check that the information given is correct. I/we understand that if false information has been given in connection with this application that my/our name will be withdrawn from the housing register. If a tenancy is granted as a result of false information supplied, the Ceredigion Housing Register may seek a Court Order for possession of the property. I/We authorise that the information provided can be checked with other organisations or agencies which the parties to the Ceredigion Housing Register consider appropriate. The Ceredigion Housing Register is operated jointly by the participating organisations and the supporting computer systems are registered under the Data Protection Act. I/We understand that any information relating to this application for re-housing will be placed on the Ceredigion Housing Register computer system and any participating organisation of Ceredigion Housing Register may see it. I/we understand that I/we may also request a copy of the data held. s signature... Date... Partner s signature... Date... (If you are making a joint application with your spouse / partner then both of you need to sign).

13 This middle section should be retained by applicant for future reference CHOOSING THE AREA WHERE YOU WISH TO LIVE. Please show the area where you would wish to be housed, you may choose up to five areas.. Make your choice of area and transfer those choices to question 5 of the main form 3. You do not have to choose five areas, you may wish to restrict your choice, but remember that this also restricts the opportunity the Ceredigion Housing Register may have in housing you 4. You will be considered automatically for any property that becomes vacant which matches your household size and is in the area that you specified as your choice. Please do not choose an area unless you are prepared to live there 5. If you are in any doubt about which areas you should choose or the choice of housing available in those areas you should consult the Housing Register Team at the address shown in the table below. 6. You may only amend your choice of areas once every six months, unless there are extenuating circumstances. Written evidence will be required. Please return form and address any correspondence to Ceredigion Housing Register at either :- North Ceredigion Ceredigion County Council: Department of Environmental Services and Housing Canolfan Rheidol, Rhodfa Padarn, Llanbadarn Fawr, Aberystwyth. SY3 3UE. Tel: Housing@ceredigion.gov.uk South Ceredigion Ceredigion County Council: Department of Environmental Services and Housing Neuadd Cyngor Ceredigion Penmorfa, Aberaeron, SA46 OPA or Morgan Street, Cardigan, SA43 DF Tel: Housing@ceredigion.gov.uk 3

14 AREAS OF HOUSING NORTH CEREDIGION ABERMAGWR ABERYSTWYTH TOWN * BLAENPLWYF * BORTH * BOW STREET * BRONANT * CAPEL BANGOR * CLARACH COMINS COCH* DEVIL S BRIDGE LLANAFAN LLANBADARN FAWR * LLANDDEWI BREFI * LLANDRE LLANFARIAN LLANGEITHO LLANGWYRYFON LLANILAR * LLANRHYSTUD* LLEDROD* PENPARCAU * PENRHYNCOCH * PONTRHYDFENDIGAID* PONTERWYD PONTRHYDYGROES SWYDDFFYNNON TALIESIN TALYBONT * TREFECHAN * TREGARON * TRE R DDOL YSBYTY YSTWYTH * MID CEREDIGION ABERAERON * ABERARTH ALLTYBLACCA * BETTWS BLEDRWS BWLCH Y LLAN CAERWEDROS CELLAN CILCENNIN CILIAU AERON CRIBYN CROSS INN (LLANON) CROSS INN (NEW QUAY) * CWRTNEWYDD DIHEWYD FELINFACH * FFOSYFFIN * GILFACHREDA GORSGOCH LAMPETER * LLANARTH * LLANON * LLANFAIR CLYDOGAU LLANGYBI LLANWNEN * LLWYNCELYN * LLWYNYGROES LLANYBYDDER* MYDROILYN NEW QUAY * PENNANT SILIAN SYNOD INN TALSARN SOUTH CEREDIGION ABERPORTH * ADPAR * BEULAH BLAENANNERCH BLAENCELYN BLAENPORTH CAPEL DEWI CARDIGAN * CENARTH * CAPEL TYGWYDD COEDYBRYN CROESLAN * CWMCOU FERWIG * FFOSTRASOL * GLANRHYD HENLLAN * LLANGRANNOG LLANDYGWYDD LLANDYSUL * LLECHRYD * PARCLLYN * PENPARC * PENRHIWLLAN * PENTREGAT PONTSHIAN * PONTGARREG PRENGWYN RHYDLEWIS SARNAU * TANYGROES TREGROES TALGARREG* * Cymdeithas Tai Cantref housing areas CSC REP ENV APPHOUS09 4