Home Choice Application Form

Transcription

1 Home Choice Application Form Housing in rth Somerset Produced for rth Somerset Housing Team by CTPLD August

2 Please fill in this form if you would like to put your name on the Housing Register. Answer all questions. Be truthful and honest. If anything changes let us know. This information will be used to find out your housing need. You may be contacted to be given advice on other housing options. If you are offered a property you will be asked to provide proof for some questions. Section 1 Support If you would like your letters to be sent to someone else, for example a support worker, advocate or your family, please fill in the section below. Full name... Their address..... Postcode Telephone number. If you need help with the form, or do not understand the questions, please ring HomeChoice Team

3 Section 2 Information about you Title (Mr, Mrs, Miss) Full name Date of birth Address Postcode How long have you lived at this address? Telephone number Mobile number Work number address Gender: Male Female Have you always lived in the United Kingdom? If no, which country did you come from? 3

4 Please tell us what your nationality is UK National Other (please say) Please tell us what your ethnic origin is White British 4 Irish Other white (please say) Dual Heritage / Mixed Race White and Black Caribbean White and Black African White and Asian White and Chinese Other white (please say) Chinese Black or Black British Caribbean African Other Black Background (please say) Asian or Asian British Indian Asian African Bangladeshi Other Asian Background (please say)

5 Are you expecting a baby? If yes, what date is the baby due? Do you have a job? If yes, please fill in the following information: What is your job? What is the name of your employer? What is your employers address? What is the telephone number of your employer?..... How long have you worked in this job? 5

6 Where have you lived for the last 5 years? I have lived at my address (as above) for more than 5 years. If you have lived at other places in the last 5 years please give details in the space below: Old Address Dates Name and Address of Landlord Please say why you left each old address. 6

7 Section 3 Information about your partner If you do not have a partner please leave Section 3 and move to Section 4 Title (Mr, Mrs, Miss) Full name Date of birth Address Postcode How long has your partner lived at this address? Telephone number Mobile number Work number address Gender: Male Female Has your partner always lived in the United Kingdom? If no, which country did your partner come from? 7

8 Please tell us what your partner s nationality is UK National Other (please say) Please tell us what your partner s ethnic origin is White British 8 Irish Other white (please say) Dual Heritage / Mixed Race White and Black Caribbean White and Black African White and Asian White and Chinese Other white (please say) Chinese Black or Black British Caribbean African Other Black Background(please say) Asian or Asian British Indian Asian African Bangladeshi Other Asian Background(please say)

9 Is your partner expecting a baby? If yes, what date is the baby due? Does your partner have a job? If yes, please fill in the following information: What is your partner s job? What is the name of your partner s employer? What is your partner s employer s address? What is the telephone number of your partner s employer?..... How long has your partner worked in this job? 9

10 Where has your partner lived for the last 5 years? My partner has lived at the address above for more than 5 years. If your partner has lived at other places in the last 5 years please give details in the space below: Old Address Dates Name and Address of Landlord Please say why your partner left each old address. 10

11 Section 4 You and your family We need to know if anyone else in your family will be moving with you. Please give their details below. Name Date of Birth Their relationship to you Do you or your partner have difficulty with reading or writing?, I do, my partner does How would you or your partner prefer to be contacted? Mobile Home Phone Number In writing 11

12 Section 5 Money and Benefits Do you or your partner have any savings in the bank or building society? If yes, what is the total amount of savings you and your partner has?. Do you or your partner receive any of these benefits? Disability Living Allowance or PIP Employment and Support Allowance Income Support or Job Seekers Allowance Housing Benefit Pension Credit Other (please say) Do you or your partner receive a care package or personal budget from Social Services? If yes, please give details: 12

13 Section 6 About where you live now What type of property do you live in? House Caravan Bed sit Flat Bungalow Prison Hospital Shared House Residential Home Other (please say) Bed and Breakfast... If you live in a flat what floor is it on? Do you have the following rooms where you live? Living Room Kitchen Bathroom Bedroom How many bedrooms? If you have any of these rooms, do you share them with other people not on this form? If yes, are they family? 13

14 Do you have a pet? If yes, what type of pet is it? Are you or your partner a wheelchair user? Has your property been changed to suit your needs? If yes, please say what has been changed 14

15 Section 7 About your housing need Do you own your home? If no, please tick one of the following choices to explain your current housing situation. Housing Association Tenant Name of Housing Association:.... Private Landlord Name of Private Landlord:.... Living with Family or Friends Accommodation comes with your job Other (please say what)

16 Do you, or anyone else who will be living with you, have: (Please tick as many as you like ) Learning Disability Physical Disability Sensory Impairment (for example hard of hearing or loss of sight) Mental Health issues A long term illness (for example cancer, diabetes or HIV) Other If yes, please say Do you need to live on the ground floor? Will you need to have adaptations to your home? If yes, what will they be? 16

17 Section 8 Declaration The information you have given will be placed on a computer system. You are able to see this information if you want to. Please check that the answers you have given are correct. It is an offence to give wrong information. If you give wrong information you may lose your property. You must tell us if anything changes, for example if you move address. I agree that you can share this information with other housing and support providers. (Please tick if you agree) Your signature Today s date Please send your form to: HomeChoice Team Town Hall Weston-super-Mare BS23 1UJ 17