Mutual Exchange Application

Transcription

1 Mutual Exchange Application Please note we will not be able to process a mutual exchange unless you have a clear rent account or if you hold a current starter tenancy. We have up to 42 days to process the exchange upon receiving this application. Section 1 to be filled in by MHA tenants only Address: Your Details Full Name: Gender: Date of Birth: National Insurance: Marital Status: First Language: Home Phone number: Mobile number: address: Sexual orientation: Religion: Tenant 2 (if you hold a joint tenancy) Other Household Occupants - Who Else Lives With You? Name Date of Birth Relationship

2 Ethnic Origin Tenant 2 (if applicable) White British Scottish British Scottish Welsh Irish Welsh Irish English English Mixed White & Black Caribbean White & Asian White & Black Caribbean White & Asian White & Black African White & Black African Asian or Asian British Pakistani Bangladeshi Pakistani Bangladeshi Black or Black British Caribbean African Caribbean African Chinese or Other ethnic group Chinese Chinese Employment Status Type of job Tenant 2 (if applicable) Full time (more than 24 hours) Full time (more than 24 hours) Part time (less than 24 hours) Part time (less than 24 hours) Self employed Self employed Serving in the armed forces Serving in the armed forces Unemployed but looking for work Unemployed but looking for work Unemployed by not job hunting Unemployed by not job hunting Retired Retired In education/ training In education/ training Home maker Home maker Care for relative or friend Care for relative or friend Not working (suffering from long term illness) Not working (suffering from long term illness) Other (specify) Other (specify) Weekly income Weekly income

3 Details of Benefits Received Disabilities Tenant 2 (if applicable) Attendance Allowance Attendance Allowance Carer s Allowance Carer s Allowance Child Benefit Child Benefit Child Tax Credits Child Tax Credits Cold weather Payments Cold weather Payments Council Tax Benefit Council Tax Benefit Disability Living Allowance Disability Living Allowance Employment & Support Allowance ( ESA) Employment & Support Allowance ( ESA) Housing Benefit Housing Benefit Income Support Income Support Incapacity Benefit Incapacity Benefit Jobseeker s Allowance Jobseeker s Allowance Maternity Allowance Maternity Allowance Mobility Mobility Pension Credit Pension Credit Personal Independence Payment (PIP) Personal Independence Payment (PIP) Universal Credit Universal Credit War Pension War Pension Working Tax Credit Working Tax Credit State Pension State Pension Other (specify) Other (specify) Registered disabled Wheelchair user Other difficulties walking Deaf Hard of hearing Blind Visually impaired Speech difficulties Long term illness Mental illness Learning difficulties Alcohol misuse Substance misuse Difficulty reading Difficulty writing Difficulty filling in forms Difficulty completing day to day tasks Other ( specify) Tenant 2 (if applicable) Registered disabled Wheelchair user Other difficulties walking Deaf Hard of hearing Blind Visually impaired Speech difficulties Long term illness Mental illness Learning difficulties Alcohol misuse Substance misuse Difficulty reading Difficulty writing Difficulty filling in forms Difficulty completing day to day tasks Other ( specify)

4 If you or a member of your household are registered disabled, has your home been adapted to meet your needs? Yes No If so please specify below: Support Needs Needs are being met Needs met now, but will need more in future Needs not being met, need more support now How do you currently access transport? Own car Bus/ Train Bicycle Motorbike Taxi Access to another person s vehicle No access to transport Tenant 2 (if applicable) Needs are being met Needs met now, but will need more in future Needs not being met, need more support now Own car Bus/ Train Bicycle Motorbike Taxi Access to another person s vehicle No access to transport The Internet Do you have access to internet? Yes, in own home Yes, in other person s home Yes, in library No access Yes, in own home Yes, in other person s home Yes, in library No access How often do you access the internet? At least daily At least weekly At least once a month Less than once a month Never signature At least daily At least weekly At least once a month Less than once a month Never Tenant 2 signature (if applicable)

5 Budget Sheet Name Address Telephone Mobile Total Savings Held Your Household Income Wages Jobseekers Allowance Income Support Employment & Support Allowance Universal Credit Working Tax Credit Child Tax Credit Child Benefit State Pension Works / Occupational Pension DLA/PIP/Attendance Allowance Other Benefits/Income: Total Income Frequency: (W/F/M/4W) Debt Payments: (e.g. loans/credit cards/overdrafts) Total Amount Universal Credit Date Claimed Payment Date Your Household Outgoings Rent Water Rates Council Tax Gas Electricity Food Contents insurance TV Licence Sky Mobile Phone Internet Travelling Expenses Clothing School Meals Hobbies Frequency: (W/F/M/4W) Other Outgoings (e.g. childcare/leisure/smoking) Total Outgoings

6 Section 2 - To be filled in by the person(s) you wish to exchange with Address: Are you current Monmouthshire Housing tenant? Yes No If you have ticked NO Please provide details of your current landlord. We will need to contact your current landlord to obtain a tenancy reference on your behalf. Do you hold a former tenancy with Monmouthshire Housing Association? Yes No Please note we will not be able to proceed with an exchange if you owe any outstanding debts to Monmouthshire Housing Association from a former tenancy. Former Address (if applicable): Your Details Full Name: Gender: Date of Birth: National Insurance: Marital Status: First Language: Home Phone number: Mobile number: address: Sexual orientation: Religion: Applicant 2 (if you hold a joint tenancy) Other Household Occupants - Who Else Lives With You? Name Date of Birth Relationship

7 Ethnic Origin Applicant 2 (if applicable) White British Scottish British Scottish Welsh Irish Welsh Irish English English Mixed White & Black Caribbean White & Asian White & Black Caribbean White & Asian White & Black African White & Black African Asian or Asian British Pakistani Bangladeshi Pakistani Bangladeshi Black or Black British Caribbean African Caribbean African Chinese or Other ethnic group Chinese Chinese Employment Status Type of job Applicant 2 (if applicable) Full time (more than 24 hours) Full time (more than 24 hours) Part time (less than 24 hours) Part time (less than 24 hours) Self employed Self employed Serving in the armed forces Serving in the armed forces Unemployed but looking for work Unemployed but looking for work Unemployed by not job hunting Unemployed by not job hunting Retired Retired In education/ training In education/ training Home maker Home maker Care for relative or friend Care for relative or friend Not working (suffering from long term illness) Not working (suffering from long term illness) Other (specify) Other (specify) Weekly income Weekly income

8 Details of Benefits Received Disabilities Applicant 2 (if applicable) Attendance Allowance Attendance Allowance Carer s Allowance Carer s Allowance Child Benefit Child Benefit Child Tax Credits Child Tax Credits Cold weather Payments Cold weather Payments Council Tax Benefit Council Tax Benefit Disability Living Allowance Disability Living Allowance Employment & Support Allowance ( ESA) Employment & Support Allowance ( ESA) Housing Benefit Housing Benefit Income Support Income Support Incapacity Benefit Incapacity Benefit Jobseeker s Allowance Jobseeker s Allowance Maternity Allowance Maternity Allowance Mobility Mobility Pension Credit Pension Credit Personal Independence Payment (PIP) Personal Independence Payment (PIP) Universal Credit Universal Credit War Pension War Pension Working Tax Credit Working Tax Credit State Pension State Pension Other (specify) Other (specify) Registered disabled Wheelchair user Other difficulties walking Deaf Hard of hearing Blind Visually impaired Speech difficulties Long term illness Mental illness Learning difficulties Alcohol misuse Substance misuse Difficulty reading Difficulty writing Difficulty filling in forms Difficulty completing day to day tasks Other ( specify) Applicant 2 (if applicable) Registered disabled Wheelchair user Other difficulties walking Deaf Hard of hearing Blind Visually impaired Speech difficulties Long term illness Mental illness Learning difficulties Alcohol misuse Substance misuse Difficulty reading Difficulty writing Difficulty filling in forms Difficulty completing day to day tasks Other ( specify)

9 If you or a member of your household are registered disabled, has your home been adapted to meet your needs? Yes No If so please specify below: Support Needs Needs are being met Needs met now, but will need more in future Needs not being met, need more support now How do you currently access transport? Own car Bus/ Train Bicycle Motorbike Taxi Access to another person s vehicle No access to transport Applicant 2 (if applicable) Needs are being met Needs met now, but will need more in future Needs not being met, need more support now Own car Bus/ Train Bicycle Motorbike Taxi Access to another person s vehicle No access to transport The Internet Do you have access to internet? Yes, in own home Yes, in other person s home Yes, in library No access Yes, in own home Yes, in other person s home Yes, in library No access How often do you access the internet? At least daily At least weekly At least once a month Less than once a month Never At least daily At least weekly At least once a month Less than once a month Never Signed applicant 1 Applicant 2 (if you hold a current joint tenancy)

10 Budget Sheet Name Address Telephone Mobile Total Savings Held Your Household Income Wages Jobseekers Allowance Income Support Employment & Support Allowance Universal Credit Working Tax Credit Child Tax Credit Child Benefit State Pension Works / Occupational Pension DLA/PIP/Attendance Allowance Other Benefits/Income: Total Income Frequency: (W/F/M/4W) Debt Payments: (e.g. loans/credit cards/overdrafts) Total Amount Universal Credit Date Claimed Payment Date Your Household Outgoings Rent Water Rates Council Tax Gas Electricity Food Contents insurance TV Licence Sky Mobile Phone Internet Travelling Expenses Clothing School Meals Hobbies Frequency: (W/F/M/4W) Other Outgoings (e.g. childcare/leisure/smoking) Total Outgoings