APPLICATION FORM FOR HOUSING ASSISTANCE PAYMENT (HAP Scheme)

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1 Version APPLICATION FORM FOR HOUSING ASSISTANCE PAYMENT (HAP Scheme) LOGO XX XX COUNCIL ADDRESS ADDRESS ADDRESS PHONE WEBSITE

2 Section A This section is to be completed by the Applicant Applicant Checklist 1. Have completed all parts (1 to 4) of Section A about you and your household. 2. Have signed the declaration section in Part 5 of Section A 3. Return a completed Landlord Section B (if this is not being returned directly by the landlord.) 4. Attach a copy of any legal custody arrangements that you may have for a member of your household. 5. Attach any supporting documents (e.g. 3 recent payslips) regarding income if this has been requested by your local authority. Notes 1. If you are applying for Housing Assistance Payment please fill out Section A about yourself and your household (Parts 1 to 5) and Section B must be filled out by the landlord (Parts 6 to 9) 2. When Section A and B are fully complete please return the form to: 3. If you are already on the waiting list for Social Housing Support please write-in your Local Authority reference number here: Enter Homeless Pass No. here if applicable: 4. If the members of your household have changed since you made your application for social housing support, you will need to update your details with the Local Authority. Depending on the change, this may mean that your housing application needs be reassessed by the Local Authority. 5. Please note that the Local Authority will only process completed application forms. Incomplete forms will be returned to the applicant. Page A-1

3 Section A Please fill in all of Section A about you and your household PART 1 - YOUR DETAILS Please fill in the blank boxes YOU (APPLICANT) YOUR SPOUSE/PARTNER (if applicable) P.P.S. Number First Name(s) Surname Date of Birth D D M M Y Y D D M M Y Y Current Address Phone/Mobile No. address PART 2 THE PROPERTY I am applying for Housing Assistance Payment to be paid on my behalf in relation to the property at Address of property Total number of bedrooms in the whole property If the property is shared, total number of bedrooms available to your household in the property/part of the property that you rent Rent for the property is Per (tick) Month Week Are you in receipt of Rent Supplement? (tick) Yes No Is the supplement payment for the property listed above? Yes No Please state the amount of supplement and total rent Amount of Supplement Total Rent paid to landlord Page A-2

4 PART 3 CHILDREN/DEPENDANTS/ANY OTHER HOUSEHOLD MEMBERS Please complete the table below about any other people in your household that will be living with you, this may include children and other adults that live with you. First name Surname Date of Birth Relationship to you e.g. my son, my sister PPS Number Do you have a custody, guardianship or fostering arrangements in Yes No relation to any of the people listed above? (tick one) If so, please give the name of the person that the custody, guardianship or fostering arrangements relates to and details of the legal arrangement below. First name Surname Details e.g. the nights that the person stays with you. Please attach a copy of any legal arrangements when returning this form. Page A-3

5 PART 4 YOUR HOUSEHOLD INCOME In the table below, please provide the latest details about your gross income (income before deductions) and the gross income of all the people in your household. Some members of your household may get income from two or three places, for example, a maintenance payment, a one parent family payment and some wages. Include each income separately in the table below. Your local authority may ask for supporting documentation to confirm income listed below. The first entry is an example to assist you in completing the table. Name of person in Employment Status Income Type Income from Other How often and when that household e.g. employed, unemployed e.g. wages, maintenance, job Employment Income amount is paid seeker s allowance ( ) ( ) e.g. monthly, weekly and day of payment John Hughes Employed part-time Wages 600 Monthly, last Thursday of month Job Seeker s Allowance 130 Weekly on a Thursday (OFFICE USE ONLY) Total gross household income Page A-4

6 PART 5 APPLICANT DECLARATION Please note that the housing authority may ask you to provide additional information or documents, in order to check the information that you have provided, you will be asked to get that information back to the local authority within four weeks. Please read this declaration carefully and sign and date it when you are satisfied that you understand it. Please note that an application for Housing Assistance Payment will only be accepted when this application form has been completed and this declaration has been signed. Collection and Use of Data: The housing authority will use the data which you have supplied to assess and administer your application for Housing Assistance Payment. Your data will be also be processed by a central administrative body involved in administrating the Housing Assistance Payment scheme. Data may be also shared with other public bodies for the purpose of the prevention or detection of fraud. The local authority may, in conjunction with the Department of the Environment, Community & Local Government, process this data for research purposes, including forward planning in relation to the assessment of housing needs. The housing authority may (for the purpose of its functions under the Housing Acts ) request and obtain information from another housing authority, the Criminal Assets Bureau, An Garda Siochána, the Minister for Social Protection, the Health Service Executive (HSE), or an approved housing body in relation to occupants or prospective occupants of, or applicants for, local authority housing. The housing authority may also, in the exercise of their housing functions, request and obtain information about any person that the authority considers may be engaged in anti-social behaviour. Declaration: I/We declare that the information and particulars given by me/us on this application are true and correct. I/We undertake to notify the housing authority of any change in my/our household circumstances (e.g. address, household composition, employment etc.). I/We also authorise the housing authority to make whatever enquiries it considers necessary to verify details of my/our application. I/We am/are aware that the furnishing of false or misleading information is an offence liable to prosecution. I/We confirm that I/we understand and accept that if my/our Housing Assistance Payment application is approved and payments commence to my/our landlord that my/our housing needs will be met and that I/we will be removed from the Local Authority s housing list. Signed (Applicant): Date: Signed (Spouse/Partner): Date: OFFICIAL USE ONLY Date valid application received Decision date Details: Page A-5

7 Section B Landlord This section is to be completed by the Landlord Landlord Application Information Check List When returning this form to your local authority you will need to: 1. Have completed all parts (6 and 7) of Section B about you and the property. 2. Have signed the declaration section in Part 9 of Section B. 3. Attach a copy of your valid Tax Clearance Certificate if this is available. If a valid Certificate is not available one must be provided to the local authority within 5 months of HAP payments commencing. 4. Attach a header from a Bank Statement, with the landlord/agent name and address to prove that the the named person/company nominated to receive HAP payments is the account holder for the bank details provided. 5. Attach proof of ownership of the property with the landlord/agent name and property address in one of the following forms. Please see Terms and Conditions point 2 page B-4 for more details: a. title deed or similar legal instrument proving ownership of the property b. evidence of current registration with the PRTB c. evidence of current paid buildings insurance policy/schedule d. evidence of payment of Local Property Tax (LPT) e. mortgage statement dated within the last 12 months If Section B is returned separately by the landlord please return to: Page B-1

8 Section B - Landlord Please fill in all of Section B, unless indicated otherwise. PART 6 LANDLORD AND BANK DETAILS P.P.S Number (for individual) Tax reference no. (For body corporate) First Name Surname Landlord Address Phone Nominated Agent details (if applicable) Agent Name Agent Address Agent phone Agent Bank details for payment (Please submit header of a Bank Statement to prove that the named person/company is the account holder) Name of Account Holder Bank name & address BIC IBAN Tax Compliance Do you hold a valid Tax Clearance Certificate? Yes No (tick) (Please attach a copy of the certificate) Certificate number (write in) If you do not hold a valid Tax Clearance Certificate, please confirm that you will obtain the certificate and send it to the local authority in the next five months (tick one). A valid Tax Clearance Certificate must be submitted annually. Yes No Page B-2

9 PART 7 PROPERTY DETAILS (please fill out in relation to the property the prospective HAP Tenant will reside in) It is proposed to let the property at: To (tenant(s) names): Tick the box which best describes the property House which is (tick one): detached semi-detached terraced Maisonette/ Duplex Apartment/Flat Studio Flat Is the accommodation self-contained? Yes No i.e. there are no other households living in the same property (tick one) If the accommodation is not self-contained, please indicate how many people live in the whole property excluding applicant household (write in) How many bedrooms are there available to this household? (not including bedrooms let to other tenants) (write in) What is the rent for the property for this household? Rent Limits are available from the Local Authority (This must be the same rent as per the tenancy agreement/rent book) Is/will there be a tenancy agreement and/or rent book Yes No in relation to this property? Rent is due (tick one) Weekly Calendar monthly Is the property furnished or unfurnished?(tick one) Furnished Unfurnished Please note that the commencement of HAP payments is subject to local authority approval For new tenants, what is the proposed tenancy start date? D D M M Y Y (write in DD/MM/YY) OR For existing tenants, what is the date that the tenant moved in D D M M Y Y to the property? (write in DD/MM/YY) Date rent is paid up to (if applicable) (write in DD/MM/YY) D D M M Y Y Date for the end of the tenancy (if applicable) (write in DD/MM/YY) D D M M Y Y Deposit for the property Deposit has been paid Yes No (write in amount) (tick one) Local Property Tax Property ID number (write in) Page B-3

10 PART 8 TERMS AND CONDITIONS Payment of the Housing Assistance Payment (HAP) to a landlord is subject to the following terms and conditions: 1. Tenancy: The applicant HAP tenant must have a valid tenancy in the property the subject of the HAP payment. 2. Ownership of the property the subject of the HAP payment: the landlord must provide proof of ownership of the property in one of the following forms (a photocopy is acceptable) a) title deed or similar legal instrument proving ownership of the property; b) evidence of current registration with the PRTB showing the landlords name and property address; c) evidence of current paid buildings insurance policy/schedule for the property (renewal notices will not be accepted); d) evidence of payment of Local Property Tax (LPT) which should include the name of the landlord, address of the property and be dated within the last 12 months or e) mortgage statement, indicating the landlord as the owner of the property and indicating the address of the rental property, and dated within the last 12 months. Proof of ownership is required irrespective of whether the landlord is receiving HAP payments directly or if payments are received by a nominated managing agent. 3. Rental Accommodation Standards: the property provided by the landlord to the tenant must comply with the Housing (Standards for Rented Houses) Regulations 2008 as amended. Further information regarding these standards can be found on the housing section of the Department of the Environment, Community and Local Government website The local authority will carry out an inspection of the property within 8 months of commencing HAP payments to ensure that the property is in compliance. If this inspection identifies matters of non-compliance with the standards, the landlord will be obliged to remedy the matter(s) of non-compliance within a time period indicated by the local authority in written notice to the landlord. Failure to remedy any matters of non-compliance within the stated timeframe will result in the suspension or cessation of HAP payments. 4. Tax compliance: to be eligible to receive HAP payments, landlords must demonstrate their compliance with all relevant tax obligations by producing a valid Tax Clearance Certificate. A valid Tax Clearance Certificate should be returned with this form. If a valid certificate is not available landlords will have up to 5 months following commencement of HAP payments to produce a valid Tax Clearance Certificate for the local authority. However, if within the 5 months, a further payment by the authority falls due which, if paid would result in total payments by the authority to the landlord in any period of 12 months exceeding 10,000, that payment will not be made without the landlord providing a valid Tax Clearance Certificate. The landlord will be obliged to produce renewed Tax Clearance Certificates at the expiration of the previous Certificate as requested by the local authority. 5. Payments: HAP payments will be made on a monthly basis in arrears by electronic funds transfer to a nominated bank account. Payments may be made directly by the local authority or by a designated third party on behalf of the local authority. Payment by a local authority to a landlord or his or her agent does not imply any liability on the part of the local authority for rent due to the landlord. This arrangement does not establish any partnership, any joint venture or landlord and tenant relationship between the landlord and the local authority. 6. Deposits: the local authority is not liable for the payment of deposits in respect of a property the subject of HAP payments. 7. Tenant rental contribution to local authority: HAP tenants will be required to pay a weekly rental contribution to the local authority. Payment of this contribution is a condition for the continued eligibility of the tenant to benefit from the local authority making HAP payments, on their behalf to the landlord. Non-payment of this rental contribution may result in suspension or cessation of HAP payments to the landlord. 8. Management of the tenancy: management of a tenancy in respect of which HAP payments are made is the sole responsibility of the landlord in accordance with the Residential Tenancies Act Avoidance of anti-social behaviour is a condition for the continued eligibility of the tenant to benefit from the local authority making HAP payments, on their behalf to the landlord. The local authority may suspend or cease HAP payments to the landlord if the tenant engages in anti-social behaviour. Page B-4

11 PART 9 - LANDLORD DECLARATION Please ensure that you have read the Terms and Conditions set out in Part 8 in full before completing the Declaration at the end of Part 9. I confirm I have read the Terms and Conditions which set out the statutory requirements and I am aware of my obligations in this regard. 1) Statement on Ownership I certify that I am the full and absolute owner of the property detailed above under Part 7 (the Property ) 2) Tax Compliance I am fully aware that I must produce a valid Tax Clearance Certificate to the local authority to receive HAP payments. I am fully aware that if I cannot return a valid Tax Clearance Certificate with this form that I will have a maximum of 5 months following commencement of HAP payments to produce a valid Certificate to the Local Authority. 3) Standards for Rented Houses I certify that the Property is in such a lettable condition that meets the following statutory requirements for rented accommodation: Housing (Standards for Rented Houses) Regulations 2008, & Housing (Standards for Rented Houses) (Amendments) Regulations I acknowledge and agree that INSERT NAME Council (the Local Authority ) will carry out an inspection in due course at the above property to ensure the property meets the standards as stated above. I am fully aware that the Local Authority will be making Housing Assistance Payments in respect of the rent due for the tenancy of the Property solely on behalf of the tenant and notwithstanding the receipt of the Housing Assistance Payments, I acknowledge and accept that the payment by the Local Authority under the Housing Assistance Payments is strictly on behalf of the tenant of the Property and that this arrangement shall not establish any contractual arrangement, any partnership, any joint venture or any landlord and tenant relationship between with the Local Authority and I. Lastly, I hereby further represent and warrant to the Local Authority and acknowledge and agree that I have had the opportunity to seek and have not been prevented from seeking independent legal advice prior to the signing of this declaration. In the event that I do not obtain independent legal advice prior to signing this declaration I did so voluntarily without undue pressure and I agree that my decision not to obtain independent legal advice shall not effect in any way the validity and enforceability of my obligations hereunder. Collection and Use of Data: The housing authority will use the data which you have supplied to administer the application for Housing Assistance Payment. Your data will be also be processed by a central administrative body involved in administrating the Housing Assistance Payment scheme. Data may be also shared with other public bodies for the purpose of the prevention or detection of fraud. The local authority may, in conjunction with the Department of the Environment, Community & Local Government, process this data for research purposes. Signed Print Name Date Page B-5

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