APPLICATION FOR Private Rental Assistance Ask if you need help with this form

ALL APPLICATIONS MUST INCLUDE PROOF OF IDENTIFICATION Housing SA APPLICATION FOR Private Rental Assistance Ask if you need help with this form The information you provide on this form will be used by Housing SA to help you with an appropriate service. If you don t provide all the information requested, Housing SA may not be able to help you. Housing SA may use the information you provide for statistical purposes. You can access the information you provide by contacting Housing SA. Eligibility for Private Rental Assistance To be eligible you must: be living in South Australia have an income paid directly to you have an active arrangement to repay your debt if you owe money to Housing SA not own or partly own any property or real estate find rental accommodation for less than 50% of your gross household income meet the income and asset limits. If you don t meet the above criteria, you might still be eligible if you have special circumstances - eg you are homeless, you have a medical condition. Talk to a Housing SA staff member if you think you have special circumstances. If there are adults, other than your partner, applying for private rental assistance with you they must fill in their own application. Applications cannot be accepted if: you don t sign the declaration on page 10 you don t provide proof of income and identity for you and anyone aged 16 and over who is included in your application. Do you need an interpreter? Contact Housing SA on 131 299 to make or cancel an appointment, or if you have any questions about this form. OFFICE USE ONLY C/N: FAMILY NAME: FRONT COUNTER Date Received / / Proof of ID Proof of Income Debt Amount Debt Arranged Debt Partner Partner Debt Arranged Sent File to Date Processed Registration User ID / / F1011 Private Rental Assistance_A4 - R1.indd 1

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PROOF REQUIRED Proof of income You must provide proof of income that is less than 2 weeks old for: yourself anyone else included on this application aged 16 and over. Tax File Numbers should be removed or covered from all proof of income documents provided. Acceptable forms of income Employer s Declaration Form, available from Housing SA. Current payslip showing gross wages, including overtime, with year to date earnings or 6 to 8 weeks consecutive payslips. Statement of Income for Housing from Centrelink showing the benefit paid in the previous fortnight. Statement or letter from Centrelink, Veterans Affairs, Austudy or other government departments, confirming current pension/benefit payments. Current letter or statement from your employer showing average gross weekly income. For self employed persons either a copy of the most recent tax return showing your net business income (gross recent income minus expenses) divided by 52 to determine weekly income or a letter from a Certified Practising Accountant or Tax Consultant showing personal gross weekly income. Statutory declaration from your parent, if they provide income, stating the weekly/monthly financial support provided and value of any other support provided. Proof of Identification You must provide current proof of identification for: yourself anyone living with you aged 16 and over. You must provide ONE form of identification from this list (must include photo and signature) Passport Current driver s licence/permit with photograph Current student or employer ID OR You must provide TWO forms of identification from this list. Marriage Certificate Life Insurance Policies Divorce Papers Current bank, credit union or building society passbook/ access card Confirmation letter from an authorised officer from Families SA, a medical/legal practitioner or a Minister of religion Apprenticeship papers, Tradeperson s certificate or letter from employer School reports or examination certificate Prison discharge certificate Birth Certificate or Extract Centrelink Concession/Health Card State Government Concession Cards Immigration Papers or other documents issued by the Commonwealth Department of Immigration Letter with common seal from Aboriginal community confirming Aboriginality Naturalisation or Citizenship Certificate Any other form of identification not listed above but deemed acceptable by Housing SA 2 F1011 Private Rental Assistance_A4 - R1.indd 2

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HOUSEHOLD DETAILS Adult household members, other than your partner or children, should make their own application for Private Rental Assistance. Provide details of all household members. Write as above if the details in one box are the same as in the box above. APPLICANT This is the person whose name the application will be in. Family name: PARTNER OTHER HOUSEHOLD MEMBERS include all other dependent adults and children MEMBER # 1 MEMBER # 2 1st name: 2nd name: Family: Have you been known by any other names? 1st: 2nd: Date of birth: / / / / / / / / Title: (eg Mr, Mrs, Ms) Male / Female: Male Female Male Female Male Female Male Female Relationship to applicant: (eg partner, son, friend) SELF Country of birth: Are you of Aboriginal or Torres Strait Islander descent? Are you or have you been under the Guardianship of the Minister? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Your current address: H: H: W: W: Your phone and contact details: M: M: E: E: Your separate postal address (if applicable): If you need more room to include other household members, turn to page 4. 3 F1011 Private Rental Assistance_A4 - R1.indd 3

HOUSEHOLD DETAILS continued Adult household members, other than your partner or children, should make their own application for Private Rental Assistance. Provide details of all household members. Write as above if the details in one box are the same as in the box above. OTHER HOUSEHOLD MEMBERS include all other dependent adults and children MEMBER # 3 MEMBER # 4 MEMBER # 5 MEMBER # 6 Family name: 1st name: 2nd name: Family: Have you been known by any other names? 1st: 2nd: Date of birth: / / / / / / / / Title: (eg Mr, Mrs, Ms) Male / Female: Male Female Male Female Male Female Male Female Relationship to applicant: (eg partner, son, friend) Country of birth: Are you of Aboriginal or Torres Strait Islander descent? Are you or have you been under the Guardianship of the Minister? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Your current address: 4 If you need more room to include other household members, ask for another form to attach to this one. F1011 Private Rental Assistance_A4 - R1.indd 4

HOUSEHOLD DETAILS continued Adult household members, other than your partner or children, should make their own application for Private Rental Assistance. Provide details of all household members. Write as above if the details in one box are the same as in the box above. APPLICANT This is the person whose name the application will be in Family name: PARTNER OTHER HOUSEHOLD MEMBERS include all other dependent adults and children MEMBER # 1 MEMBER # 2 1st name: 2nd name: If you do not speak English, what language do you speak? Physical (Eg: paraplegic, arthritis) Physical (Eg: paraplegic, arthritis) Physical (Eg: paraplegic, arthritis) Physical (Eg: paraplegic, arthritis) If you have a disability that we should be aware of, tick all applicable boxes: Vision Impaired Vision Impaired Vision Impaired Vision Impaired Hearing Impaired Hearing Impaired Hearing Impaired Hearing Impaired Intellectual Intellectual Intellectual Intellectual Mental Health Mental Health Mental Health Mental Health Other Disability Other Disability Other Disability Other Disability If you are a Refugee, when did you arrive in Australia? (you may need to provide proof) Do you own or partly own any property or real estate? If you are renting, how much is your share of the rent? (Amount in $) Yes No Yes No Yes No Yes No Type of government payment received? (Eg: NewStart, DSP) Amount of government payment received? Amount of gross wage received? Other income type? (Eg: maintenance payments) Amount of other income received? Centrelink Number (CRN) (1234567X): Veteran Affairs File Number (SPX 00110): Current cash or market value of your assets?* INCOME DETAILS: Weekly Household Income (before tax). Only complete relevant boxes. * Assets include the current cash or market value of all savings, any property or real estate, shares, bonds and other investments, compensation payouts, personal life insurance policies, motor vehicles, caravans and boats, household contents and personal effects. If you need more room to include other household members, turn to page 6. 5 F1011 Private Rental Assistance_A4 - R1.indd 5

HOUSEHOLD DETAILS continued Adult household members, other than your partner or children, should make their own application for Private Rental Assistance. Provide details of all household members. Write as above if the details in one box are the same as in the box above. Family name: OTHER HOUSEHOLD MEMBERS include all other dependent adults and children MEMBER # 3 MEMBER # 4 MEMBER # 5 MEMBER # 6 1st name: 2nd name: If you do not speak English, what language do you speak? Physical (Eg: paraplegic, arthritis) Physical (Eg: paraplegic, arthritis) Physical (Eg: paraplegic, arthritis) Physical (Eg: paraplegic, arthritis) If you have a disability that we should be aware of, tick all applicable boxes: Vision Impaired Vision Impaired Vision Impaired Vision Impaired Hearing Impaired Hearing Impaired Hearing Impaired Hearing Impaired Intellectual Intellectual Intellectual Intellectual Mental Health Mental Health Mental Health Mental Health Other Disability Other Disability Other Disability Other Disability If you are a Refugee, when did you arrive in Australia? (you may need to provide proof) Do you own or partly own any property or real estate? If you are renting, how much is your share of the rent? (Amount in $) Yes No Yes No Yes No Yes No Type of government payment received? (Eg: NewStart, DSP) Amount of government payment received? Amount of gross wage received? Other income type? (Eg: maintenance payments) Amount of other income received? Centrelink Number (CRN) (1234567X): Veteran Affairs File Number (SPX 00110): Current cash or market value of your assets?* INCOME DETAILS: Weekly Household Income (before tax). Only complete relevant boxes. * Assets include the current cash or market value of all savings, any property or real estate, shares, bonds and other investments, compensation payouts, personal life insurance policies, motor vehicles, caravans and boats, household contents and personal effects. 6 If you need more room to include other household members, ask for another form to attach to this one. F1011 Private Rental Assistance_A4 - R1.indd 6

PRIVATE RENTAL ASSISTANCE 1. What type of housing do you live in now? Please tick ( 3 ) one box. Private house/flat/unit HF Hospital/nursing home HN Housing SA, Community or Aboriginal Housing Hotel/motel/caravan HM Shelter/supported housing SH College/University housing Boarding house/hostel BH Correctional facilities CO Homeless/no accommodation HS CU N Other O You may need to provide proof of the above. 2. What are your current living arrangements? Owner/buyer B Living with parents L Sharing with other family/friends S Renting/boarding R Moving between family/friends M Homeless/no accommodation N Other O How long have you been at your current address? 3. a) Do you need to leave your current housing? If yes, what date do you need to leave by? b) Why do you need to leave? (can be more than one reason) My lease has expired L I cannot afford the rent R I do not like where I live D I have separated from my partner P I have been asked to leave/notice to quit Q My safety is at risk S I have been given an eviction notice E I am at risk of domestic violence V My house is too crowded C My house is in an unsafe/unhealthy condition H I must move because of medical reasons M I do not have a permanent place to stay N Location of current housing is unsuitable LU Other O c) Have you been looking for another place to stay? Continue with this question Go to question 4 d) Have you been able to find another place to stay? Go to question 4 Continue with this question e) Why do you think you have not been able to find another place to stay? I need help with the bond and rent BR I have not found any suitable houses NS Land agents or owners refuse my application LA Other O You may need to provide proof of the above. 4. Do you have a pet/s? If yes, provide details 7 F1011 Private Rental Assistance_A4 - R1.indd 7

PRIVATE RENTAL ASSISTANCE continued 5. Private Rental Assistance Details YOURSELF YOUR PARTNER a) Are you living in South Australia? b) Are you an overseas student? c) Will you be renting from a family member? (If yes, your family member must complete a Statutory Declaration stating that they will not be living in the property with you). d) Is this the first time you have rented privately? e) If you have a current private rental bond that Housing SA provided, has the property owner/ agent agreed to release the bond? If yes, has the property owner/agent signed a bond release form? (Forms are available from any Housing SA office). f) Do you need help with rent arrears? If yes, why? (You must provide proof of arrears - eg a letter from property owner or agent, a Notice of Termination). g) What date did you last receive income? / / / / 8 F1011 Private Rental Assistance_A4 - R1.indd 8

PRIVATE RENTAL ASSISTANCE continued 6. Have you found a place you would like to rent? IF IF Fill out the declaration section on page 10, and return this form to Housing SA. What date does your tenancy start? / / You must now: 1) have the property owner/agent fill out the Property Owner/Agent s Declaration Form on page 12 2) return this application form and the Property Owner/Agent s Declaration Form to Housing SA for assessment. You must return your Property Owner/Agent s Declaration Form with: proof of income no more than 2 weeks old for everyone aged 16 and over included in this application form proof of identification for everyone aged 16 and over included in this application form. A list of what can be accepted as proof of income and proof of identification is on page 2. 9 F1011 Private Rental Assistance_A4 - R1.indd 9

DECLARATION 1. APPLICANT DECLARATION must be completed and signed by the applicant I/We declare that all information I/we have given is true and correct. I/we understand that any assistance obtained because of incorrect or false information supplied by me/us may be withdrawn and/or subject to repayment. I/We confirm that all persons named on the form are aware that their personal information is being disclosed to Housing SA. I/We understand that I/we may become ineligible if my/our circumstances change. I/We understand that if I/we incur any debt to the SA Housing Trust now or in the future, I/we will be required to pay the amount I/we owe in full or arrange and make regular payments towards the debt, or my/our access to future services may be affected. I/We authorise Housing SA to make enquiries to find my/our new address and consent to details of my/ our new address being supplied to Housing SA if I/we move address without notifying Housing SA and I/ we have an outstanding debt to the SA Housing Trust. I/We understand that Housing SA will keep the information provided on this form confidential, except as required by Act of Parliament or Court Order, or where disclosure is authorised by the State Government s Information Privacy Principles, or where authorised by me/us. If others have completed this form on my/our behalf, they have explained the relevant questions and clauses to me/us. I/We authorise Housing SA to contact me/us during my/our private rental tenancy for the purposes of providing information and advice about the bond assistance provided to me/us. I/We DO/DO T give permission for other people named onthis application to be provided with information about this application if they ask (cross out whichever does not apply). Name Signature Date / / 2. PARTNER DECLARATION Name Signature Date / / 3. OTHER PERSON DECLARATION (to be signed if another person has completed the form on behalf of the applicant). This form has been completed with the information the applicant supplied to me. I drew the applicant s attention to the above clauses, and they have agreed that they understand. Name Relationship to applicant Signature Date / / 10 F100-4 MAY 2015 F1011 Private Rental Assistance_A4 - R1.indd 10

FINANCIAL ASSISTANCE AGREEMENT I/We agree to complete a Bond Refund Form or an online refund proposal at the end of the tenancy and submit it to the Consumer and Business Services, Customer Services Centre, to ensure the bond is repaid or released to Housing SA. I/We give authority under the Residential Tenancies legislation for the bond to be repaid or released to Housing SA. I/We authorise Housing SA to disclose our current address (if known) to Consumer and Business Services and the South Australian Civil and Administrative Tribunal in the event that Housing SA determines to contest a Property Owner/ Agent claim against Housing SA s bond in respect of previous accommodation occupied by me/us. I/We understand that if any part of the bond has been repaid by me/us to Housing SA, then that part shall be refunded to me/us after any monies payable to the PropertyOwner/Agent from the bond have been deducted. If the assistance is being provided to more than one person: Housing SA may disclose my personal financial information to other parties who are part of this application, for the purpose of collecting repayments Housing SA can collect repayments from one, or more than one, of us as it decides. I/We understand that any amount of the bond not returned to Housing SA will be raised as a debt which must be repaid in full or I/we must arrange and make regular repayments towards the debt or my/our access to future services may be affected. I/We understand that if I/we authorise another person to collect the bond on my/our behalf that I/we will be fully responsible for any monies owing to Housing SA as a result of claims made against the bond. Type of Assistance Amount Cheque or guarantee number Date Customer number Customer name Customer s signature Circle method of assistance: Posted to Agent/Collected in person/posted to Property owner/posted to agreed Agency. 11 F1011 Private Rental Assistance_A4 - R1.indd 11

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HAVING THIS FORM COMPLETED DOES T GUARANTEE ASSISTANCE Housing SA PROPERTY OWNER/AGENT S Declaration Form Before you start: This form is to be: completed by the property owner/agent when the tenancy has been confirmed and financial assistance is required. returned to Housing SA before financial assistance can be authorised. Completing this form does not guarantee that Housing SA will provide bond assistance. Tenancy Declaration: (WARNING: False declarations carry legal penalties) Name(s) of tenant(s) Share of total weekly rent Tenant Details (Include the names of everyone who will be responsible for contributing to the rent): 1. $ 2. $ 3. $ 4. $ 5. $ 6. $ New Phone Number (if known): Type of House (Please tick one): House/Unit/Flat H Boarding/Rooming B Other O Type of Housing (Please tick one): Private Rental Co-operative Association Other Address of Property to be Let: Total Weekly Rent: $ Total Weekly Board: $ Bond Charged: $ Terms of Lease (eg. 2 years, 6 months): Years Months Periodic Tenancy Start Date: / / If rent is owing state date rent is paid to: / / Are you the Property Owner/Agent? (Please tick one): Property Owner Agent Name of Property Owner/Agent (Print in full): Trading As: Address of Property Owner/Agent: Postcode: Owner/Agent Telephone Number: Owner/Agent Email Address: Owner/Agent Signature: Date: / / 12 F1011 Private Rental Assistance_A4 - R1.indd 12

FINANCIAL ASSISTANCE APPROVAL FORM For Office Use Only Customer name: Customer number: Customer name: Customer number: Customer name: Customer number: Customer name: Customer number: Financial Assistance is subject to customer providing: Assistance approved: Valid to: Contact Office: Housing Officer: General Information Housing SA offices are open Monday to Friday - 9.00am to 5.00pm. 1. If you have an outstanding debt to the SA Housing Trust, financial assistance may not be approved. 2. Before financial assistance can be issued, you must provide proof of income no more than two weeks old, proof of identity, and a Property Owner/Agent s declaration. 3. All applicants receiving financial assistance are required to collect their cheques/ guarantees in person and sign for them. 4. If you require financial assistance in future, make sure you contact Housing SA BEFORE you leave your current tenancy. If you can t collect the bond in person, you must provide written authorisation for another person to collect and sign for it on your behalf. This authorisation must clearly state that you understand you will be responsible for any outstanding monies owing to the SA Housing Trust or that result from a bond claim. 13 F1011 MAY 2015 F1011 Private Rental Assistance_A4 - R1.indd 13