Housing Application Form

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Housing Application Form Please read this form carefully and fill in details for you and the joint applicant if there is one (a joint applicant is an adult applying for a joint tenancy with you).

1 Housing Application Form Please read this form carefully and fill in details for you and the joint applicant if there is one (a joint applicant is an adult applying for a joint tenancy with you). Fill in all sections of the form that apply to you. If you have any questions, or if you need this form in another language or you need help filling it in, we are happy to help. Just call us on PLEASE RETURN THIS FORM TO: Staffordshire Housing Association, 308 London Road, Stoke-on-Trent, ST4 5AB 1

2 Application Number (staff use only): Section 1: Your details NAME & CONTACTS You Joint Applicant Mr, Mrs, Miss, Ms, Dr etc. First name Surname or family name Previous names (if applicable) Daytime telephone Mobile telephone Work telephone address Address including postcode Time living at current address Name, address and telephone of your current landlord, agent or housing association. We will contact them for a reference. What is your current housing situation (please underline your selection) Your relationship to joint applicant Other: Other: PROPERTY OWNERSHIP You Joint Applicant Do you own any property in the UK or abroad? If yes, give details: PERSONAL DETAILS You Joint Applicant Date of birth Age Gender National Insurance number First language

3 ETHNICITY You Joint Applicant White White British White Irish White Other Mixed White & Black Caribbean White & Black African White & Asian Other Asian or Asian British Indian Pakistani Bangladeshi Other Asian Black or Black British Caribbean African Other Chinese Chinese Other Gypsy/Romany /Traveller Other (please state) NATIONALITY You Joint Applicant Please state nationality FAITH You Joint Applicant Christian Muslim No religion Atheist Prefer not to say Other (please state) SEXUALITY You Joint Applicant Heterosexual/straight Gay, lesbian or bisexual Prefer not to say RELATIONSHIP TO STAFFORDSHIRE HOUSING You Joint Applicant Are you related or do you have a close association to any staff or board member of the Staffordshire Housing Group? If you have answered yes, please give details:

4 Section 2: People who will live with you Please give details of anyone who will live with you, including children OTHER PEOPLE Person 1 Person 2 Person 3 Mr, Mrs, Miss, Ms etc. First name Surname/family name Date of birth Ethnic origin Relationship to you Employment status List any disabilities Does this person need a ground floor home? If someone needs the ground floor, please say why: Section 3: Your previous addresses Have you had difficulty managing a tenancy before? Yes No (If yes, we may refer you for tenancy training) PREVIOUS ADDRESS NO.1 You Joint Applicant Address including postcode Reason for moving Name, address and telephone number of landlord, agent or housing association Date moved in and out In: Out: In: Out: At your previous address, were you a: (please underline your selection) Other (please describe): Other (please describe):

5 PREVIOUS ADDRESS NO.2 You Joint Applicant Address including postcode Reason for moving Name, address and telephone of landlord, agent or housing association Date you moved in and out In: Out: In: Out: At your previous address, were you a: (please underline your selection) Other (please describe): Other (please describe): OTHER PREVIOUS ADDRESSES You Joint Applicant List any other addresses you have had in the last 5 years: Section 4: Employment and income Do you have a bank account? (We cannot offer you a home without one) EMPLOYER DETAILS You Joint Applicant Employer s name Occupation Address and telephone number of employer INCOME DETAILS You Joint Applicant Income What is your average weekly household income?

6 Section 5: Benefits BENEFIT DETAILS You Joint Applicant Jobseekers Allowance Income Support Child Benefit State Pension Pension Credit Working Tax Credit DLA Care AMOUNT YOU RECEIVE AMOUNT THEY RECEIVE DLA Mobility Carer s Allowance ESA Other (say which) Other (say which) Is your household entitled to Housing Benefit? Full Part No Don t Know Section 6: Why you want to move Please tell us why you want to move. Tell us if you are homeless or about to be made homeless. Also state any medical or job-related reasons for moving and anything else you feel is important. If you are moving to Staffordshire from another area, please give names and addresses of relatives you want to move near to if applicable. Continue on back page if necessary.

7 Section 7: Communicating with you We send out a weekly showing our list of vacant homes to rent. Please give us the address you would like this sent to. If you need us to communicate with you in another way, please state how: Where did you hear about Staffordshire Housing Association? Advert in local paper Staffordshire Housing event Advertising board Internet Another agency Friends/family Other (please state): Section 8: Our lettings policy We aim to create sustainable tenancies and stable communities. Because of this, we have an exclusion policy which enables us to exclude households from our register if proven evidence exists that they have a history of significant non-payment of rent or significant housing debt with any local authority or housing association; they have a history of nuisance, violence or anti-social behaviour; or they have been convicted of certain criminal offences. We will inform you if we exclude you from our register and you will have the right to appeal. Have you or anyone in your household been involved in any type of behaviour that can be classed as anti-social or nuisance behaviour in the last 5 years? If yes, give details below. Yes No Have you or anyone in your household been convicted of a crime? Give details below. Offence Date of conviction Sentence received Sentence served Have you or anyone in your household ever been in trouble with the police in any other capacity, e.g. caution? If you answered yes to the above, please give details below. Yes No If you have a probation officer, please give their full contact details. We will need to ask them to provide a letter of support before we can give you a home. Probation officer name:

9 Section 9: Health, medical and wellbeing We ask for this information to ensure that your new home will meet your needs. (please underline your selection) You Joint Applicant Do you consider yourself to be disabled? Are you a wheelchair user? Do you have Autistic Spectrum Disorder? Do you have mental health difficulties? Do you have any unseen disabilities which affect your ability to live independently? Do you have other disabilities? Do you need ground floor accommodation? If you have answered yes to any of the above, please explain how your disability affects you: (please underline your selection) You Joint Applicant Do you have any problems with your health or mobility? If yes, please describe: If yes, please describe? Do you have external support, e.g. from a social worker, CPN, health visitor, care worker or psychiatrist? If yes, give the name, address and phone number of your support provider: If yes, give the name, address and phone number of your support provider: Do you have a history of, or are you currently experiencing issues with drug or alcohol abuse? For how long have you been/ were you affected? For how long have you been/were you affected? If you have overcome addiction, what help did you receive?

10 Section 10: Documents required You must provide original documents - not photocopies - to prove that you are eligible to rent a property in the UK. You must bring them to us yourself in person at our head office at 308 London Road, Stoke on Trent, ST4 5AB, or speak to us to make other arrangements. If you do not do this you will not be offered a home. What you need to bring: Evidence of your National Insurance Number for all applicants or occupants over the age of 16, in the form of: A pay slip from your employer OR Original benefit paperwork issued by HMRC, the local authority or JobCentrePlus on behalf of the Department of Work and Pensions AND Identification for all applicants and occupants listed on this form. We can accept: Your passport Your National Identification Card Your residence card Your current immigration status documents provided by the Home Office If you cannot supply the above, you must bring two of the following: A birth certificate or adoption certificate issued in the UK A current full or provisional UK driving license Original benefit paperwork issued by HMRC, the local authority or JobCentrePlus on behalf of the Department of Work and Pensions

11 Section 11: Data protection By signing this form you are giving Staffordshire Housing Association permission to store personal and sensitive data about you on our computerised housing register. The information you have given on this form will be stored on our computer system. Our staff will use it when they are letting homes. You are allowed to inspect the information we hold about you on our computer system. This information is supplied to you to comply with the provisions of the current Data Protection Act. Section 12: Requirements for tenancy When your application has been accepted by SHA, you will be expected to: - Place your register of interest on properties available via our weekly homes to rent information (via or online) - Be ready to move at the specified tenancy ready date when you are offered a property - Be prepared to pay one month rent in advance when you take on a tenancy Section 13: Declaration I/we hereby certify that the details on this form are correct and I/we will notify Staffordshire Housing Association if my/our circumstances change. I/we understand that any false or misleading statement or withholding any relevant information now or later might lead to my/our application being cancelled or any tenancy granted to me/us being ended. I/we hereby authorise any person or body to disclose to Staffordshire Housing Association any information it requires, including financial details. Signed:... Date:... Signed:... Date:...

SHELTERED HOUSING APPLICATION FORM

SHELTERED HOUSING APPLICATION FORM Dear Applicant Answer all the questions as fully as possible and enclose appropriate supporting letters or evidence. An incomplete or unsigned form will be returned to