Application for an Almshouse

Transcription

1 Application for an Almshouse CONDITIONS OF ENTRY: The King Edward VI & Revd Joseph Prime Almshouse Charity provides housing for people in need over 21 years of age who have strong connections with Saffron Walden. IMPORTANT NOTE: Please ensure that you have completed ALL sections (where not applicable write N/A), in BLOCK CAPITALS throughout, signed the declarations in Sections 4, 5 and 7, and enclosed any supporting evidence, before you return this form. We cannot consider applications that are incomplete. If you require help filling out this form, please advise the Clerk. Section 1 About You Title... First names... Surname... Current Address Postcode... Telephone: Landline... Mobile... address... Length of time at current address... Council Tax Band... Date of Birth... Age... Marital status... Employment History: Please give details of any occupations you have followed and for how long. Any present occupations should be included: Section 2 About your Family Next of kin... Relationship... Address Postcode... Telephone: Landline... Mobile... Do you have children? Yes No If YES and under 21, please state their ages... Registered Charity Number (AF010816) Page 1 of 6

2 Section 3 About your present home Type of accommodation: House Bungalow Flat Hostel Mobile home Other please give details... Do you, or your spouse, own it? Yes No If YES state estimated current value... If you do not own the property where you currently live, who does own this property? Is this person related to you in any way? Yes No If YES what is the relationship? If rented, please give name and address of landlord: Name... Address Postcode... Current rent per week Do you receive Housing Benefit? Yes No Do you receive Council Tax Benefit? Yes No Why do you wish to leave your present accommodation? What are your intentions regarding your current property if you are appointed to an almshouse? Is there a mortgage or rent outstanding on the property? Yes No If Yes, how much?... If there is no mortgage, please write NONE... If you or your partner own property other than the one in which you live, please give details below. This should include property owned abroad as well as in the UK: Address Postcode... Other... Registered Charity Number (AF010816) Page 2 of 6

3 Section 4 Statement of Income & Savings To enable the Trustees to assess your financial status, please provide the following information. We require details of all sources of income and how regularly you receive them (tick column as appropriate): Earnings 1. From Employment 2. From Self-employment Amount Per Week () Per Month () Per Year () Pensions 1. State Retirement Pension 2. Pension paid by a past employer 3. Private Pension 4. Widow s Pension 5. Any other pension Social Security Benefit 1. Pension Credit 2. Attendance Allowance 3. Child Benefit 4. Income Support/Job Seekers Allowance 5. Working Families Tax Credit 6. Personal Independence Payment 7. Any other benefits Other Income 1. Annuities 2. Bank Deposit Account interest 3. Building Society Account interest 4. Investment interest 5. Renting property or land that you own 6. Grants from a charity 7. Financial assistance from a relative/friend 8. From a Trust Fund 9. Any other income please give details Registered Charity Number (AF010816) Page 3 of 6

4 Your Savings & Debts 1. Bank accounts (current & savings accounts, please indicate) 1a.Bank... Current balance... 1b. Bank... Current balance... 1b. Bank... Current balance Building Society accounts Building Society... Current balance Shares... Current value National Savings Certificates... Current value Unit Trusts... Current value NS&I Premium Bonds... Current value... Further information about bank accounts and savings (continue on separate sheet of paper if necessary)... You are obliged to declare any OUTSTANDING DEBTS, in particular to Uttlesford District Council (UDC) or previous landlords. Please tick/complete as follows: I confirm that I have no outstanding debts: Signature... I have outstanding debts as follows: UDC: Amount... Bank: Amount... Former landlord: Amount... Credit Card: Amount... Other (name)... Amount... List details of any other debts here (continue on a separate sheet of paper if necessary)... PLEASE NOTE: If you are invited for interview you will be required to bring with you, bank statements for current and savings accounts for the three months immediately preceding the interview date. Section 5 About your Health and Social Factors Are you able and willing to look after yourself and your accommodation?... Please give details of any significant illnesses, injuries or operations during the last five years Registered Charity Number (AF010816) Page 4 of 6

5 Are there any other health or social factors that you would wish the trustees to take into consideration when assessing your application? Are you receiving continuing treatment for any of the above? Name and address of your GP or Medical Practice Postcode... MEDICAL CONSENT AUTHORITY: The charity may wish to write to your GP requesting a medical certificate. Please sign below to signify your authority to do so, should this be deemed necessary. Signature... Do you have a conviction which is not spent under the Rehabilitation of Offenders Act 1974? Yes No If YES, please provide details: Section 6 References Please give the names and addresses of two responsible people (not relatives) who know you well and whom the charity may approach for a reference Postcode... Postcode... Relationship... Relationship... Section 7 Declaration I have read the Charity s Conditions of Entry and believe that I am eligible to apply to live in one of the Charity s Almshouses. I have read the sample Letter of Appointment and agree to abide by it should I be appointed to an Almshouse. Registered Charity Number (AF010816) Page 5 of 6

6 I declare that the information given in this application is correct and complete to the best of my knowledge and belief. I understand that if I accept an offer of housing and it is subsequently discovered that I have given false or misleading information, or failed to disclose information relevant to my housing application, King Edward VI & Rev Joseph Prime Almshouse Charity may take enforcement action against me in order to end my Beneficial Appointment. I accept that if I am appointed as a Resident I shall be a Beneficiary of the Charity and not a tenant. Any weekly sum I pay will be a maintenance contribution and not a rent. I confirm that I am able to look after myself, with the assistance of family and Social Services if necessary Signature... Name... Date... (BLOCK CAPITALS PLEASE) Data Protection Statement: it is part of the Trustees responsibilities to ensure that applicants for Almshouses are suitably qualified under the terms of the Charity s governing document. Trustees, therefore, need to investigate the personal circumstances of applicants. The personal data supplied on this form and other information relating to an Almshouse appointment or your care management will be held on file. Some details may be checked with relevant organisations but none will be disclosed for any inappropriate purpose. You may have access to your personal information on request. Please return your completed application to: Alison Maslen, Clerk to the Charity, Saffron Walden Almshouses, Abbey Lane, Saffron Walden CB10 1DE For Office Use only Date Application received... Application complete Yes No Assessed by: Trustee 1... & Trustee 2... Recommended for interview Yes No Post-interview assessment... Further recommendation... Registered Charity Number (AF010816) Page 6 of 6