HOUSING APPLICATION FORM

Transcription

1 Peter Hervé House Eccles Court Tetbury Gloucestershire GL8 8EH Tel: [01666] Fax: [01666] Website: The National Benevolent Charity is a national charity providing housing accommodation for retired and elderly people, particularly those on low incomes. It was founded by Peter Hervé more than 200 years ago. Apartments are available in Tetbury, Gloucestershire and Old Windsor, Berkshire. In Tetbury, the staff are available to provide some assistance to residents and in Old Windsor there is a warden service. However the Charity is not able to provide personal care. Applicants should, normally, be aged 50 or over and retired. Preference will be given to ladies and gentlemen who live on low incomes and who have limited savings. Housing Benefit may be payable to residents who qualify under the rules. All applications will be considered by the Charity s trustees, whose decision will be final. HOUSING APPLICATION FORM Personal Details Please fill in Title: Forename: Surname: Date of Birth: Place of Birth: Married / Widowed / Single / Divorced (Delete as applicable) Religion: Present address: Mobile: National Insurance No: Length of residence at current address: Date of retirement: Last employer: [1]

2 Financial Circumstances (Please provide documentary evidence) Earnings: (if any) State Pension: Other Pension: Pension Credit: Attendance Allowance/DLA: Housing Benefit: Council Tax Benefit: Other Benefit: Investments: (Please indicate the total value of any savings or investments) Home Circumstances Are you: (Please tick) Owner/Occupier Council Tenant Housing Association Tenant Tenant of Private Landlord Caravan/Mobile Home Living with a relative Lodging In property tied to a job Other: If you are an owner/occupier please state: Value of Property: Outstanding Mortgage: Will you Sell or Let Property: Monthly Mortgage Payment: If you are not an owner/occupier please state: (This reference will not be taken without your prior agreement) Name of Landlord: Rent: Weekly/Monthly (Delete as applicable) Arrears: Sent: Office use only [2] Rec d:

3 Reason for wanting to move (Please tick) Unable to afford/maintain property Sharing with others Lonely Ill health Accommodation too large About to be made homeless Subject to harassment Move nearer to relatives Other: Health & Support Needs Name and address of Doctor: Chronic Illnesses: Current Medication: Are you Registered Disabled? Do you have a Social Worker? Name of Social Worker? Do you own/drive a car? Do you have a pet? If so please state type, size and age: Do you currently receive help from Family/Social Services/Nursing Services/or other agency with: Bathing: Dressing: Cooking: Shopping: Housework: Any other: [3]

4 Where did you hear about The National Benevolent Charity? Is there any other information which you feel will be helpful in considering your application? Is there anyone that you would like us to contact to discuss your application on your behalf? Please give the name of a relative or friend who would be responsible for you. For example, signing an operation consent form or taking action should you become incapacitated. Name: Relationship: (Please state) Mobile: [4]

5 References Please could you give the names of two people (not family), who have known you for at least three years and can vouch for your good character. Referee One: Name: Referee Two: Name: Office use only Sent: Rec d: Sent: Rec d: Accommodation Peter Hervé House / Lenox House / The Tapestries (Delete as applicable) Ground Floor / First Floor / 1 Bedroom / Studio (Delete as applicable) Apartment number: If you have any questions regarding this form please do not hesitate in contacting: Accommodation Manager (01666) [weekdays between 9am & 3pm] Signed: Print: Date: After completing this form please sign and return to: The National Benevolent Charity Accommodation Manager Peter Hervé House Eccles Court Tetbury Gloucestershire GL8 8EH [5]

6 [6]