St Albans Rent Secure Scheme Referral Form

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1 St Albans Rent Secure Scheme Referral Form Please provide the following information along with the supporting documents listed on the eligibility criteria to enable the STARSS co-ordinator to make an initial assessment to determine whether you are eligible for assistance with private rented sector housing. This form must be signed by the applicant. Delay in providing the supporting documents will lengthen the assessment process. Name (In Full).. DOB:.. Housing Benefit No: National Insurance No.. Tel No:... Mobile No: address Current Address or Last Accommodation.... Tenancy Commencement (If appropriate)..... Please give details of previous housing history (for last 7 years if possible) including periods of times spent at various addresses and reasons for leaving the accommodation, please continue on a separate sheet if necessary. Dates From to Address Name of Landlord Type of Occupancy e.g. Tenant/Lodger/ Owner Reason for leaving

2 Dates From to Address Name of Landlord Type of Occupancy e.g. Tenant/Lodger / Owner Reason for leaving Please supply details of other agencies working with the applicant: Organisation :...Tel No:... Name of Support worker Please give details of any needs eg: medical health, physical disabilities, mental health, drug, alcohol, budgeting or gambling: Please give details of any known, spent or pending convictions: Please state source of income? Eg benefits, wages etc (including amount and frequency) If employed please give name and address of present employer.....

3 Do you have any savings? If so how much Do you have any rent arrears or outstanding debts? If so please detail.. Please give details of any local connection:... Any other information that you feel would be helpful with you application Name of referring agent : Contact Number:.. Date :

4 Gender: Male Female Are you the same gender as you were assigned at birth? Yes No Prefer not to say Sexual Heterosexual Lesbian Gay Man Bisexual Rather not say Orientation: Religion: None Christian Buddhist Hindu Jewish Muslim Sikh Other Rather not say Can we contact household in English: Yes No If no, what language to use : Verbally: Written: Special Requirements:Braille Large Print Tape Type: Secondary Joint Disability: Hearing Impairment Visual Impairment Restricted mobility Wheelchair used out of home Wheelchair used in and out of home Other disability If other disability please give brief details No disability Preferred Method of Contact: Any Letter Telephone Economic Status: Full time work>30hrs Part-time work <30hrs Govt Trg/New Deal Retired Full time Student Reg Unemployed/Job Seeker Long term sick/disabled Not seeking work/at home Child under 16 Other Prefer not to say Ethnic Origin Tick one only White British White Irish Any other white bkgrnd Caribbean African Any Other black bkgrnd WB WI AOWB CAR AFR AOBB Indian Pakistani Bangladeshi Any other Asian bkgrnd White & Black Caribbean White & Black African IND PAK BANG AOAB WBC WBA White Asian Other Mixed Chinese Traveller Gypsy Any Other WA OMIX CHIN TRAV GYP AO

5 Each applicant is subject to a credit reference, land registry check and police check if applicable. Please read the declaration below and sign if you are happy for these checks to be conducted. I give permission to check the information given on this form and to make any necessary enquiries to confirm the information, or to obtain further related information (including contacting present and previous landlords, employers, doctors, the Home Office, Social Services or any other relevant agency). This may also include making enquiries with a credit checking agency, Land Registry and police check. I understand that to knowingly give false information or to withhold information is an offence and that action may be taken against me. Signed Dated..

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