housing application form · full central heating gas fires no heating part central heating electric...

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APPLICANT

Full name

Current address

Postcode

Housing Application Form

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CHISLEHURST & SIDCUP HOUSING ASSOCIATION HOUSING (CSHA) APPLICATION FORM

You must complete ALL sections of this form

Please answer in the boxes provided, by writing clearly or ticking where appropriate

1. Name and address - couples or two adults should fill in both sections

APPLICANT PARTNER/JOINT APPLICANT

Title (Mr/Mrs/Ms/Miss)

Surname

First name(s)

Date of birth

National Insurance Number

Present address

Postcode

Home telephone number

Work telephone number

Mobile number

Email address

Do you or your partner/joint applicant have any mental or physical disabilities


Mental disability Yes No Yes No

If Yes, please specify

Physical disability Yes No Yes No

If Yes, please specify

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2. Please give details of your Next of Kin (other than Partner/Joint Applicant)

APPLICANT JOINT APPLICANT/PARTNER

Name

Relationship to you

Home/Work number(s)

Mobile number

Email address

3. Reason for housing—please tick the main reason you wish to be rehoused

Home too large/too small Asked to leave by family or friends

Home in need of major repairs To take up work

Health reasons Local connection

To give or receive care Homeless

Suffering violence or harassment Member of the Armed Forces

Subject to Immigration Controls Other

If any of the above are ticked, please specify and give any other information that you feel explains

why you wish to be rehoused

If you have been asked to leave your present home, please give details below and include the date

you will have to leave together with copies of any legal notices or letters from family/friends

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4. Please give details of your present accommodation

ALL QUESTIONS TO BE COMPLETED

Type of property:

Flat/Maisonette House Bed & Breakfast

Bedsit Bungalow Hostel/Refuge

Other (please specify)

On which floor do you live?

Ground First Second Third

Yes No Is there a lift?

Total no. of bedrooms in property Double Single No. of bedrooms you use

Owner/occupier? Tenant? Are you or your partner

Lodger? In tied accommodation? Other (please specify)

If you own a home, amount of equity £

If property has been owned we need proof of equity. If the property is still for sale, this is a copy

of the estate agent valuation and mortgage statement. If property is sold, this is a copy of the

completion statement.

We cannot accept applications from anyone with savings or equity in excess of £50,000.

Who else lives in the property but will not live with you when you move?

First name(s) Surname Gender (M or F) Relationship to you Date of birth

Years Months How long have you lived at your present address?

Yes No Do you own, or have a tenancy of any other residential property?

If you are a tenant, name and address of landlord of Applicant

Landlord

Address

Postcode Contact Number (s)

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Years Months How long have you lived at your present address?

Yes No Do you own, or have a tenancy of any other residential property?

Name and address of landlord of Partner/Joint Applicant

Landlord

Address

Postcode

Do you share bathroom or kitchen facilities with people who are not family or friends?

Please give details:

How is your home heated? Full central heating Gas fires No heating

Part central heating Electric or open fires

If your home is in need of major repairs (e.g. rewiring, roof repairs) please give details

Yes No Has an Environmental Health Officer visited your address?

If yes, please enclose a copy of the report.

Yes No Do you currently have rent arrears?

If yes, please specify

Yes No Do you have a record of antisocial behaviour?


Yes No Do you have any unspent criminal convictions?


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5. Previous addresses - please give details of all the addresses where you and your

partner have lived over the past 5 years

Applicant

Date from Address

Date to Postcode

Reason left

Was the property rented/owned with family or friends (please delete)

If rented name and address of landlord

If the property has been sold, please include a copy of the completion statement

Applicant

Date from Address

Date to Postcode

Reason left




Partner/Joint Applicant

Date from Address

Date to Postcode

Reason left




Partner/Joint Applicant

Date from Address

Date to Postcode

Reason left




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6. Details of accommodation you require

Please list the scheme areas where you would prefer to live (in order of preference)

1. 2.

3. 4.

How many bedrooms do you need?

Yes No Do you need ground floor accommodation?

Would you prefer accommodation where there is a full-time

Sheltered Housing Manager? Yes No

Please give details of any special facilities required for any person with disabilities

Please give details if you or any member of your family cannot return to live in the home due

to ill health or disability (e.g. where the hospital will not discharge the patient due to the current

home being unsuitable)

Please give details if anyone to be rehoused cannot use part of his/her present home (e.g.

cannot climb stairs)

Please give details if the health of anyone to be rehoused is made worse by his/her present

home or location

If you have any other information relating to your health or disability that will help us to deal

with your application please give details on a separate sheet. Please enclose a letter from

your doctor to support your application.

Do you have private vehicles? Yes No If yes, how many?

PLEASE NOTE THAT NO PETS ARE ALLOWED IN OUR SHELTERED ACCOMMODATION

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Current job

Name of employer

Address of employer

Postcode

Take home pay (£ per week)

In which Borough do you work

How long have you been with your current employer

7. Income details (we are asked to provide the Government with financial information

covering all new lets)

Income from work

APPLICANT

Current job

Name of employer

Address of employer

Postcode

Take home pay (£ per week)

In which Borough do you work

How long have you been with your current employer

PARTNER/JOINT APPLICANT

APPLICANT Yes Amount

No

Attendance Allowance £

Disability Living Allowance (DLA) £

Employment and Support Allowance (ESA) £

Incapacity Benefit £

Income Support £

Personal Independence Payment (PIP) £

Other State Benefits (please specify) £

Benefits - please tick all that apply and enter amount for each:

Job Seeker’s Allowance (JSA) £

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State Pension £

Workplace Pension £

Other Pension (please specify) £

Savings & Investments (please give details) £

£

Benefits - continued:

APPLICANT Yes Amount

No

State Pension £

Workplace Pension £

Other Pension (please specify) £

Savings & Investments (please give details) £

£

8. Relationship to employees or Board Members of Chislehurst & Sidcup HA

Yes No Are you or your partner/joint applicant employed by CSHA?

Are you or your partner/joint applicant related to a Member of the Board or an

employee of CSHA? Yes No

If yes, please give details:

9. Rejection and Exclusion Policy

The use of violence or the threat of violence against any tenant, employee, Board Member, or

Agent of Chislehurst & Sidcup HA, or anyone else lawfully on the scheme? Yes No

Harassment of others, as listed immediately above? Yes No

Does one or more of the criteria listed below apply, or has it applied during the last 6 years, to you

and/or to members of your household?

PARTNER/JOINT APPLICANT Yes Amount

No

Attendance Allowance £

Disability Living Allowance (DLA) £

Employment and Support Allowance (ESA) £

Incapacity Benefit £

Income Support £

Personal Independence Payment (PIP) £

Other State Benefits (please specify) £

Job Seeker’s Allowance (JSA) £

Benefits - please tick all that apply and enter amount for each:

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Causing wilful damage to property? Yes No

Arson? Yes No

Forfeiture of a probationary tenancy? Yes No

A history of anti-social behaviour? Yes No

A record of repetitive car crime, burglary or other criminal damage? Yes No

A history of drug related offences? Yes No

A record of offences against children? Yes No

A record of other criminal offences that have a relation to community matters? Yes No

A conviction for a criminal offence, other than a spent conviction under the

Rehabilitation of Offenders Act 1974? Yes No

If yes, please give details below including date of offence plus name and address of probation officer

10. Communication

What is your first spoken language?

What is the main language you read?

Are you happy with this form and the information we have provided to you? Yes No

If no, how would you like us to communicate with you? (Please tick below)

Large print Translation/other language Cassette/tape Braille

Other (please comment)

Family & Friends Newspaper Council/Housing Association

IT/Web Site Local Advertising Other

Where did you find out about Chislehurst & Sidcup HA? (Please tick below)

11. Please provide the contact details for your GP


Doctors name

Address

Contact Number

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I/we have made an application for housing with:- Chislehurst & Sidcup HA

I/we understand that Chislehurst & Sidcup HA will need to carry out enquiries concerning my/our

character and conduct of any previous tenancies or occupations of any property in the past

I/we give my/our permission and consent for Chislehurst & Sidcup HA to obtain any relevant

information about me/us from all relevant agencies. I/we understand that the relevant agencies

may include, but are not limited to, any police force, previous landlords, Probation Service, Social

Services and Education Departments of local authorities

I/we give my/our permission for Chislehurst & Sidcup HA to seek medical information in connection

with this application and a fee may be payable

I/we understand that this information will be used for the sole purpose of assisting my/our housing

application, and will be held in the strictest confidence. This includes information protected by the

Data Protection Act 1998.

Both applicants must sign if the application is a joint one

Signed (Applicant) Date

PRINT NAME

Signed (Partner/Joint Applicant) Date

PRINT NAME

Please ensure all sections of this form are completed. Partially completed forms will not be

accepted

Both applicants must sign if the application is joint

Signed (Applicant) Date

Signed (Partner/Joint Applicant) Date

13. Statement

I confirm that I have completed the Informed Consent Section of this application form. I

confirm that the details given in this application are true. I understand that if I have knowingly

or recklessly given any false information, or withheld information in connection with this

application, my accommodation may be repossessed by virtue of Schedule 2 of the Housing

Act 1985 (as amended)

12. Informed Consent


Full name

Current address

Date of birth

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14. Equality and Diversity

Your application will not be treated differently because of your colour, ethnic or national origin,

nationality, gender, sexual orientation, marital status, physical or learning disability, age or religion.

Choose one option that best describes your ethnic group or background:

Please return this completed form to:

Asian/Asian British – Bangladeshi Black - Any Other Background White - British

Asian/Asian British – Indian Chinese White - Gypsy or Irish Traveller

Asian/Asian British – Pakistani Mixed/White & Asian White - Irish

Asian – Any Other Background Mixed/White & Black African White - Any Other Background

Black/Black British – African Mixed/White & Black Caribbean Other Ethnic Group - Arab

Black/Black British – Caribbean Mixed - Any Other Background Other Ethnic Group - Any Other

Chislehurst & Sidcup Housing Association

45 Invicta Close

Chislehurst

Kent

BR7 6SJ

FOR OFFICE USE ONLY

Application No.

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