Don t forget to. Chesterfield

Transcription

1 Name Chesterfield BOROUGH COUNCIL Housing Application Form Please answer all the questions as fully as you can. Where there is a box, please mark clearly with a o3. If you do not provide sufficient information, we may not be able to register your application and it may be returned to you for completion. Don t forget to o Sign and date the form before returning it to us at Housing Solutions Centre, 73 Low Pavements, Chesterfield S40 1PB. o For every applicant, include at least two forms of proof of identity and one proof of current address. Forms of Identification Proof of current address o Full Birth Certificate o Recent Bank Statement o Medical Card o Council Tax Bill o Marriage Certificate o Recent Utility Bill o Driving Licence o Mobile Phone Bill o Passport o Proof of Benefits (not housing benefit) o Include a birth certificate for every child on the application o Include a child benefit or tax credit award letter naming each child needing to live with you. o Proof of clear rent account for all Council and Housing Association tenancies ever held and private tenancies in the last 5 years for both main and joint applicants. We must see the original documents, photocopies will not be acceptable. See page 15. Remember o Your application form will not be registered for accommodation until all the required documentation is provided. o If you have any difficulty completing the form or providing the required documentation, please contact us on Fax: Chesterfield Borough Council s choice based lettings scheme. For more information please visit or visit the Housing Solutions Centre, 73 Low Pavements, Chesterfield S40 1PB 5299

2 PART 1 - Interested Parties Title... Surname... Forenames... Previous Names... Date of Birth... Gender... Marital Status o Single o Married o Divorced o Living together o Separated o Widowed National Insurance Number... Home Address Post Code... Date moved in... Home Telephone Number... Mobile Telephone Number... Work Telephone Number... Address... Contact Address... Title... Surname... Forenames... Previous Names... Date of Birth... Gender... Marital Status o Single o Married o Divorced o Living together o Separated o Widowed National Insurance Number... Home Address Post Code... Date moved in... Home Telephone Number... Mobile Telephone Number... Work Telephone Number... Address... Contact Address... Relationship to main applicant - e.g spouse, child, partner, friend... 2

3 PART 2 - Equal Opportunities Monitoring Form Please help us ensure we are providing a fair service and fill in the following details Please tick the appropriate box to indicate your background. A) White C) Asian or Asian o British British o Irish o Indian o Polish o Pakistani o Italian o Bangladeshi o Other... o Italian o Other... B) Mixed D) Black or Black o British British o White & Black o Caribbean Caribbean o African o White & Black o Other... African E) Other Ethnic o White & Asian Group o Other... o Chinese o Gypsy o Other... Please tick the appropriate box to indicate your religion. o None o Buddhist o Christian o Hindu o Jewish o Muslim o Sikh o Other... o Prefer not to say Please tick the appropriate box to indicate your background. A) White C) Asian or Asian British British Irish Indian Polish o Pakistani Italian o Bangladeshi Other... o Italian o Other... B) Mixed D) Black or Black o British British o White & Black o Caribbean Caribbean o African o White & Black o Other... African E) Other Ethnic o White & Asian Group o Other... o Chinese o Gypsy o Other... Please tick the appropriate box to indicate your religion. o None o Buddhist o Christian o Hindu o Jewish o Muslim o Sikh o Other... o Prefer not to say Disability The definition of Disability in the Disability Discrimination Act 1995 is A physical or mental impairment which has substantial and long term adverse effect on a person s ability to carry out normal day to day activities. Do you consider yourself to be disabled? Yes No If yes, what are your impairments? Please tick all that apply. Mobility Visual Speech Hearing Wheelchair User Learning Disability Mental Health Condition inc. Depression Long Standing Health Condition e.g. Cancer, HIV Other Please State... Do you consider yourself to be disabled? Yes No If yes, what are your impairments? Please tick all that apply. Mobility Visual Speech Hearing Wheelchair User Learning Disability Mental Health Condition inc. Depression Long Standing Health Condition e.g. Cancer, HIV Other Please State... 3

4 PART 3 - Previous Addresses Tenure: OO - Owner Occupier, CT - Council Tenancy, PT - Private Tenancy, HA - Housing Association, FF - Family or Friends, Please state if not listed You must tell us all of your previous addresses for the last five years Address Tenure Date Date Reasons for Leaving From To You must tell us all of your previous addresses for the last five years Address Tenure Date Date Reasons for Leaving From To PART 4 - Landlord s Details Who is your landlord? o Chesterfield Borough Council o Tenant of another Council o Tenant of a Housing Association o Tenant of a Private Landlord o Tenant of another Landlord o In Lodgings/living with friends or family o In a caravan/mobile home that I rent If your landlord is not Chesterfield Borough Council please provide their name and address. Telephone number... Who is your landlord? o Chesterfield Borough Council o Tenant of another Council o Tenant of a Housing Association o Tenant of a Private Landlord o Tenant of another Landlord o In Lodgings/living with friends or family o In a caravan/mobile home that I rent If your landlord is not Chesterfield Borough Council please provide their name and address. Telephone number... 4

5 PART 4 - Landlord s Details continued Is there any rent or other debt owing on any tenancy? Yes No If yes please give details a) which address... b) amount owing... c) why the debt happened d) when and what arrangements have been made to pay it e) what payments are you making Is there any rent or other debt owing on any tenancy? Yes No If yes please give details a) which address... b) amount owing... c) why the debt happened d) when and what arrangements have been made to pay it e) what payments are you making PART 5 - Who needs to be re-housed with you? First Name(s) Surname Gender Date of National Relationship Access to Birth Insurance to Main children number Applicant No. of nights per week * * Please note: proof of access or joint custody to children will be required for your application to be updated eg. birth certificate/proof of child benefit. 5

6 PART 6 Other people living with the main applicant but will NOT be moving with you First Surname Gender Date of National Relationship Name(s) Birth Insurance to Main number Applicant PART 7 Criminal Convictions Have you or any members of your household been convicted of any offence Yes o No o Name and details of offence Conviction Sex Offence or Current/Previous Not Spent Schedule One Offence Probation Officer Yes No Yes No Yes No 6 Has legal action been taken against you or anyone who wants housing with you for Anti-Social Behaviour? i.e. Eviction, Injunction, ASBO. Yes o No o If yes please tell us why they received it......

7 PART 8 - Your Current Home Type of home you live in o House o Flat Ground Floor Yes o No o o Maisonette Ground Floor Yes o No o o Bedsit Ground Floor Yes o No o o Bungalow o B&B o Prison o Caravan o Other - Please state... How many bedrooms o 0 o 1 o 2 o 3 o 4 o Other - Number... What type of heating do you have? o Gas Central Heating o Solid Fuel Central Heating o Electric Storage Heaters o District Heating o No Heating o Other - Please state... Are you: (please tick only one) o A Council Tenant o In Hospital o A Housing o In Housing for Association Tenant Older People o An Owner Occupier o In Prison o An Owner Occupier o In any other (low cost home Temporary ownership) Accommodation o A Private Tenant o In a Foyer o In Tied Housing or o In Short Life Rented with Job Housing o In Supported o In a Mobile/ Housing Caravan o In a Probation o In a Women's Hostel Refuge o In a Residential o In a Direct Care Home Access Hostel o Living with Family o In Bed & Breakfast o Living with Friends o Rough Sleeping o In Home Office o In a Children's Asylum Support home/foster care o Renting a room (in shared house) o Other - Please state... Type of home you live in o House o Flat Ground Floor Yes o No o o Maisonette Ground Floor Yes o No o o Bedsit Ground Floor Yes o No o o Bungalow o B&B o Prison o Caravan o Other - Please state... How many bedrooms o 0 o 1 o 2 o 3 o 4 o Other - Number... What type of heating do you have? o Gas Central Heating o Solid Fuel Central Heating o Electric Storage Heaters o District Heating o No Heating o Other - Please state... Are you: (please tick only one) o A Council Tenant o In Hospital o A Housing o In Housing for Association Tenant Older People o An Owner Occupier o In Prison o An Owner Occupier o In any other (low cost home Temporary ownership) Accommodation o A Private Tenant o In a Foyer o In Tied Housing or o In Short Life Rented with Job Housing o In Supported o In a Mobile/ Housing Caravan o In a Probation o In a Women's Hostel Refuge o In a Residential o In a Direct Care Home Access Hostel o Living with Family o In Bed & Breakfast o Living with Friends o Rough Sleeping o In Home Office o In a Children's Asylum Support home/foster care o Renting a room (in shared house) o Other - Please state... 7

8 PART 8 - Your Current Home continued Do you have the use of the following facilities? o Inside WC Yes o No o o Bath or Shower Yes o No o o Hot/Cold Water Yes o No o o Wash Hand Basin Yes o No o o Do you share a kitchen or a bathroom with anyone not related to you? Yes o No o Is your home adapted for accessible living? This could include a stair lift, ramp to front door, grab rails in your bathroom etc Yes o No o If yes, with what... Do you have the use of the following facilities? o Inside WC Yes o No o o Bath or Shower Yes o No o o Hot/Cold Water Yes o No o o Wash Hand Basin Yes o No o o Do you share a kitchen or a bathroom with anyone not related to you? Yes o No o Is your home adapted for accessible living? This could include a stair lift, ramp to front door, grab rails in your bathroom etc Yes o No o If yes, with what... PART 9 - Medical Information Are you or anyone moving with you pregnant? Yes o No o If yes, when is the baby due? DD/MM/YYYY... Is your home unsuitable for you due to a medical condition? Yes o No o If yes, please complete a medical assessment form. If yes, why is the property unsuitable? Do you need an extra bedroom for medical reasons? Yes o No o If yes, why?... Do you consider yourself or any member of your household to be disabled? Yes o No o Please provide details of the disability Name of Person with the disability Details of the disability Is it essential that the person with the disability has Yes o No o wheelchair access into and around the home? Are there any adaptations that would be required to Yes o No o your new home to help with your/their needs? If yes, please state what adaptations are required Are you leaving hospital care and unable to return to your home? Yes o No o Please state name of hospital and ward...

9 PART 10 - Support Do you need to move to give essential support? Yes o No o Do you need to move to receive essential support? Yes o No o Who to or from o A relative o someone you are a carer for o relatives for childcare to enable parent to remain in employment Address of person giving or receiving support. PART 11 - Your Finances/Assets Do you currently claim any benefits? o Yes o No If yes, what benefits do you claim? Put a o4 in any boxes that apply to you. o Universal Credit o Employment Support Alowance o Income Support o Job Seekers Allowance o Incapacity Benefit o Working Tax Credit o Child Tax Credit o Housing Benefit o Council Tax Benefit o Attendance Allowance o Child Benefit o Disability Living Allowance o Retirement Pension What rate DLA do you claim? o High o Middle o Low If you are employed/self employed, what is your net weekly income? (Excluding childcare but including Working Tax Credit) Do you need to move to give essential support? Yes o No o Do you need to move to receive essential support? Yes o No o Who to or from o A relative o someone you are a carer for o relatives for childcare to enable parent to remain in employment Address of person giving or receiving support. Do you currently claim any benefits? o Yes o No If yes, what benefits do you claim? Put a o4 in any boxes that apply to you. o Universal Credit o Employment Support Alowance o Income Support o Job Seekers Allowance o Incapacity Benefit o Working Tax Credit o Child Tax Credit o Housing Benefit o Council Tax Benefit o Attendance Allowance o Child Benefit o Disability Living Allowance o Retirement Pension What rate DLA do you claim? o High o Middle o Low If you are employed/self employed, what is your net weekly income? (Excluding childcare but including Working Tax Credit) 9

10 PART 12 - Your Employment Working full time Working part time Government Training/New Deal Job Seeker Retired Voluntary unpaid work Full Time Student Unable to work Carer Working full time Working part time Government Training/New Deal Job Seeker Retired Voluntary unpaid work Full Time Student Unable to work Carer Number of hours worked per week... Job Title... Name of Employer... Address of Employer... Your occupation (please tick) Teacher (Nursery/Primary) Teacher (Higher/Further) Teaching Assistant Education Welfare Officer Police Officer Police Civilian Officer Prison Service Operational Support Care Worker (Private Sector) Care Worker (Public Sector) Child Protection Officer Social Worker Probation Officer Probation Service Admin Support Town Planner NHS Nurse/Midwife NHS other medical NHS Admin Support Bus/Tram/Train Driver Transport Police None of the Above. Please state Number of hours worked per week... Job Title... Name of Employer... Address of Employer... Your occupation (please tick) Teacher (Nursery/Primary) Teacher (Higher/Further) Teaching Assistant Education Welfare Officer Police Officer Police Civilian Officer Prison Service Operational Support Care Worker (Private Sector) Care Worker (Public Sector) Child Protection Officer Social Worker Probation Officer Probation Service Admin Support Town Planner NHS Nurse/Midwife NHS other medical NHS Admin Support Bus/Tram/Train Driver Transport Police None of the Above. Please state

11 PART 13 - Reasons For Moving From the following options please tick the reason you need to move. Please tick all boxes that apply to you. You are overcrowded Your property is too large for your family Property unsuitable for medical reasons Property is in poor condition Affordability mortgage/rent too high To move nearer to family/friends/school To move nearer work To move to accommodation with support To move to independent accommodation Loss of tied accommodation Assured Shorthold tenancy has ended Eviction or repossession Domestic Violence Relationship breakdown with partner Asked to leave by family or friends Racial harassment Problems with neighbours Left home country as refugee Discharged from prison/longstay hospital Decanted by CBC to another property Other PART 14 - Living outside of the UK What is your nationality?... Have you lived in another country in the last five years? Yes No If YES, in which country?... When did you come to live in this country? DD/MM/YYYY... Do you have indefinite leave to remain in the UK? Yes No We may require further information. Do you have exceptional, extended, leave to remain in the UK? Yes No Have you been accepted by the Home Office as a refugee? Yes No What is your nationality?... Have you lived in another country in the last five years? Yes No If YES, in which country?... When did you come to live in this country? DD/MM/YYYY... Do you have indefinite leave to remain in the UK? Yes No We may require further information. Do you have exceptional, extended, leave to remain in the UK? Yes No Have you been accepted by the Home Office as a refugee? Yes No Are you an asylum seeker? Yes No Are you an asylum seeker? Yes No Did you enter the UK on the basis of a sponsorship undertaking? Yes No Did you enter the UK on the basis of a sponsorship undertaking? Yes No 11

12 PART 15 - Area and Property Type Preference In this section, we ask for information about where you would like to live. This information will help us when we make nominations to Housing Associations or direct match allocations if we need to. Although you have given this information it does not mean that we will be able to offer you a home in that area. Please tick all areas you would consider. ANY SOUTH AREA Hasland Grangewood Spital St Augustines Boythorpe Brampton Whitecotes Hady ANY NORTH AREA Highfields Newland Dale/Hazlehurst Old Whittington New Whittington Peveril Racecourse/Shaw Street Brimington CHESTERFIELD TOWN CENTRE ANY STAVELEY AREA Barrow Hill Duckmanton Inkersall Lowgates/Hartington Middlecroft Mastin Moor Poolsbrook Staveley Town Centre ANY WEST AREA Dunston Newbold Newbold Moor Pevensey Loundsley Green Holme Hall Green Farm Close Littlemoor Would you consider accommodation provided by another landlord? Please tick the type of accommodation you require. Please note you will only be able to bid for accommodation for which you are eligible. Bedsits 1bed 2 bed 3 bed 4 bed House Flat - Ground Floor Flat - Above Ground Floor Maisonette Bungalow Sheltered Accommodation 12

13 PART 16 - Other Housing Options Mutual Exchange Council and Housing Association tenants may exchange properties providing they have written permission from their landlords. The mutual exchange list is a way of finding someone to exchange with. If you apply, the details about your property will be displayed on the Home swapper website ( If you are interested please tick in the box provided Homebuy (Shared Ownership) Homebuy requires the applicant to buy a share of the price of a particular Housing Association property (normally half) and rent the remaining share from the Housing Association. The owned share can be gradually increased until the whole property is bought. Further information is available from Housing Services. If you are interested please tick in the box provided PART 17 - Additional Information Do you have any pets? Yes No If yes please tell us how many pets you have e.g 1 dog and 2 cats... Do you require any future correspondence in the following formats? Braille Large Print Tape Other... Do you have a...? Name Contact Address Tel. Number Social Worker Probation Officer Health Visitor Community Psychiatric Nurse Connexions Personal Advisor Is anyone helping you to be rehoused? PART 18 - Further Information - Please tell us why you want to move Please use an additional sheet of paper if required and staple to the application form. 13

14 PART 19 - Declaration FOR THE ATTENTION OF ALL APPLICANTS IMPORTANT NOTICE HOUSING ACT 1996 s.171 & s.214 FALSE STATEMENTS Where a person approaches Housing Services seeking an allocation of housing or claiming to be homeless or threatened with homelessness, the above Act makes it an offence, punishable with a fine, for a person to make a false statement or to withhold information which is relevant to their claim. For homeless applicants it is also an offence to fail to inform the housing authority of any material changes in circumstances which may occur between the initial interview and such time as notification of the Council s decision is received. NATIONAL FRAUD INITIATIVE NOTIFICATION TO DATA SUBJECTS (HOUSING RENTS) This Authority is under a duty to protect the public funds it administers, and to this end, may use the information you have provided on this form within this Authority for the prevention and detection of fraud. It may also share this information with other bodies administering or in receipt of public funds solely for these purposes. Please tick one of the following statements: I am an Officer or Member of Chesterfield Borough Council I am a close relative/close friend of an Officer or Member of Chesterfield BC None of the above apply to me If you are a relative/close friend of an Officer or Member, please state their name and the nature of your relationship. (e.g. son, daughter etc.) Name...Relationship... FOR THE ATTENTION OF ALL APPLICANTS. DECLARATION The information I provide is accurate. I understand that if I obtain accommodation by providing inaccurate information, the Council may take legal action to recover the property. I also agree to give Housing Services the authority to contact any third party for information that it reasonably requires in connection with this application and give my permission for this information to be released to it. Signature of Applicant... Date... Signature of Joint Applicant... Date... 14

15 PART 20 - What to do now PLEASE CHECK THAT YOU HAVE o Filled in the application form for yourself, a joint applicant and other members of your household, if applicable. o Signed the declaration on page 14. o Included the required proof of identity, proof of current address and clear rent accounts. Until you provide the required proof we will not be able to register your application. o o Only original documents will be accepted. If you find it necessary to post these important documents then please ensure that it is sent by recorded or special delivery. Any documents will then be photocopied by a member of staff and returned to you. Checked the price of posting this form and any other supporting proof, if you are sending it through the post. Failing to put the correct postal price on your envelope may result in applications not being received and processed. 15

16 COUNCIL CONTACTS Customer Services / 5 / 6 Reporting repairs during office hours FREEPHONE Repair.Requests@Chesterfield.gov.uk Repairs - Emergency Only (out of hours) Neighbourhoods Team Neighbourhoods.Team@Chesterfield.gov.uk Housing Services Fax Homelessness Team / / Housing.Advice@Chesterfield.gov.uk Homelessness (out of hours) Welfare Reform Enquires / Rents and Rent Recovery / Environmental Services / 5 / 6 Housing & Council Tax Benefit Text / Voice Messages Minicom ARE WE ACCESSIBLE TO YOU? IF NOT - ASK US! We want everyone to be able to understand us. We want everyone to be able to read our written materials. We aim to provide what you need for you to read, talk, and write to us. On request we will provide free Language interpreters, including for sign language. Translations of written materials into other languages. Materials in Braille, large print, on tape or Easy Read. Please contact us: Voice telephone Fax Mobile text phone SMS eoinfo@chesterfield.gov.uk North Derbyshire Home Improvement Agency Careline Chesterfield BOROUGH COUNCIL 16