and Wear Homes Housing application - South Tyneside

Thank you for applying to Tyne and Wear Homes.

Housing application

Tyne and Wear Homes is a lettings partnership that will allow youto search and apply for properties from across Tyne and Wear.

The five main authorities - Gateshead, Newcastle, North Tyneside, South Tyneside and Sunderland, and their respectivehousing organisations - have joined together to bring you an easier way to access all of the housing options available.

Your application is important to us so if you need any assistance completing it contact your housing provider - details are at the back of this form.

Please note, failure to fully complete this form could result in adelay in processing your application.

Tyne and WearHomes

Date received (internal use only):

2

Section 1 – Personal details (sections marked with a ‘*’ must be completed)

Other (please state)

Please choose: Please choose:

AutisticBlindDeafHearing impairmentLearning disabilityMental healthMobilityProgressive disability/chronic illness Speech impairmentUnseen impairmentVisual impairmentNoneOther

Please choose:

AutisticBlindDeafHearing impairmentLearning disabilityMental healthMobilityProgressive disability/chronic illness Speech impairmentUnseen impairmentVisual impairmentNoneOther

Please choose:

Miss Mrs Mr Ms

Other (please state)

Relationship to mainapplicant

Title*

First name*

Surname*

Have you been known byany other names (i.e. amaiden name)? If soplease provide details:

Date of birth*

Gender*

Do you have a disability?

Main applicant

Not applicable

Joint applicant

MaleFemaleTransgender (male to female)Transgender (female to male)

Please choose:MaleFemaleTransgender (male to female)Transgender (female to male)

Please choose:

Miss Mrs Mr Ms

Yes No Yes No

3

Do you require additionalsupport due to:

Do you have a supportworker?

If yes, please provideagency name and contactdetails:

National insurance number*

Which language wouldyou prefer to use?

Main applicant Joint applicant

Please choose: Please choose:

Alcohol dependenceDrug dependenceLearning difficultiesLeaving care of the local authorityLeaving hospitalLeaving prisonLeaving supported housingMental health issueMobility difficultiesPhysical health issuesSensory issues - blindSensory issues - deafSensory issues - withoutspeechWheelchair user

Alcohol dependenceDrug dependenceLearning difficultiesLeaving care of the local authorityLeaving hospitalLeaving prisonLeaving supported housingMental health issueMobility difficultiesPhysical health issuesSensory issues - blindSensory issues - deafSensory issues - withoutspeechWheelchair user

4

Nationality*

Ethnic origin*

How would you describeyour sexuality?*


Asylum seekerBulgarianCzech RepublicEstonianHungarianLatvianLithuanianNon EEA nationalOther EEA nationalPolishRomanianSlovakianSlovenianUK national

Please choose:

Asian any otherAsian BangladeshiAsian IndianAsian PakistaniBlack AfricanBlack any otherBlack CaribbeanChineseMixed otherMixed White and Black AfricanMixed White and Black AsianMixed White and Black CaribbeanWhite any otherWhite BritishWhite IrishOther ethnicPrefer not to say

Please choose:Asian any otherAsian BangladeshiAsian IndianAsian PakistaniBlack AfricanBlack any otherBlack CaribbeanChineseMixed otherMixed White and Black AfricanMixed White and Black AsianMixed White and Black CaribbeanWhite any otherWhite BritishWhite IrishOther ethnicPrefer not to say

Please choose:

Asylum seekerBulgarianCzech RepublicEstonianHungarianLatvianLithuanianNon EEA nationalOther EEA nationalPolishRomanianSlovakianSlovenianUK national

Please choose:

BisexualGay manGay woman/LesbianHeterosexual (straight)Not knownPrefer not to say

Please choose:BisexualGay manGay woman/LesbianHeterosexual (straight)Not knownPrefer not to say

Please choose:

5

Religion*


AgnosticAtheistBuddistChristianHinduHumanistJudaismMuslimSikhNoneNot knownOtherPrefer not to say

Please choose:AgnosticAtheistBuddistChristianHinduHumanistJudaismMuslimSikhNoneNot knownOtherPrefer not to say

Please choose:

Section 2 - Current address details

Address 1* (House number or name)

Address 2* (Street)

Address 3

Address 4

Address 5 (County)

Postcode*

Date moved into this property*

What type of tenancy ortenure do you have?

Home telephone number

Work telephone number

Mobile telephone number

E-mail address


6

Section 3 - Other details

Same as current address?

Description*

Contact name (if applicable)*

Address 1* (House number or name)

Address 2* (Street)

Address 3

Address 4

Address 5 (County)

Postcode*


Yes No Yes No

FamilyFriend’sHome Other

Parent’s SolicitorWork

Please choose:FamilyFriend’sHome Other

Parent’s SolicitorWork

Please choose:

Are you pregnant?

If yes, when is the babydue? You may need to provide a MAT B1 form ora letter from doctor.

Are you moving fromabroad?

Are you any of the following?


Yes No Yes No

Yes No Yes No

Please choose:EEA worker (not subject toHome Office Worker Registration or Authorisation Schemes)Accession national subject to Home Office Worker Registration or Authorisation SchemeSelf-employedPerson granted refugee statusPersons granted other protection leave (humanitarian protection)Indefinite leave to remain/enter the UKOther

Please choose:EEA worker (not subject toHome Office Worker Registration or Authorisation Schemes)Accession national subject to Home Office Worker Registration or Authorisation SchemeSelf-employedPerson granted refugee statusPersons granted other protection leave (humanitarian protection)Indefinite leave to remain/enter the UKOther

Contact address:

7

Yes No Yes No

Yes No Yes No

Yes No

Yes No Yes No

Yes No

How would you like to becontacted?*

Do you have access to theinternet?

Are you able to visit a Customer Service Centre or housing office?

Do you require help withbidding?

Will anyone other thanyou or the joint applicanthave authority to bid onyour behalf?

If yes, please provide nameand contact details:

Are you or is any memberof your family related to acouncil, board or staffmember of one of thepartner landlords?


Audio tapeBrailleE-mailHome visitLanguage lineLarge printLetterMinicomMobileOther languageSame sex interviewTelephone - homeTelephone - workTextText typeType talkOther (please state)

Please choose:

Audio tapeBrailleE-mailHome visitLanguage lineLarge printLetterMinicomMobileOther languageSame sex interviewTelephone - homeTelephone - workTextText typeType talkOther (please state)

Please choose:

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If yes, please provide details of the council,board or staff member:

Are you or is any memberof your family employedby one of the partnerlandlords?

If yes, please provide fulldetails, including wherethey work:

Has any housing relatedlegal action been takenagainst you?

If yes, what was this for?

Please provide details including address at timeof action and date:

Landlord, bank or financial provider:

Have you any convictionsother than spent convictions?

If yes, please provide fulldetails including date:


Yes No Yes No

Yes No Yes No

Yes No Yes No

Mortgage arrearsNuisanceRent arrearsDamage to the propertyOther anti-social behaviourOther housing related debt

Please choose:Mortgage arrearsNuisanceRent arrearsDamage to the propertyOther anti-social behaviourOther housing related debt

Please choose:

GatesheadNewcastleNorth TynesideSouth TynesideSunderland

Please choose:GatesheadNewcastleNorth TynesideSouth TynesideSunderland

Please choose:

If yes, authorisation must be signed for a police check.

9

Court address and sentence:

Which is your first choicelocal authority?*

Which is your preferredarea(s) of that local authority (please refer tothe Tyne and Wear Homesguide to estates)?

What is your preferred estate(s) (please refer tothe Tyne and Wear Homesguide to estates)?


Local connection

Do you have a local connection with any of the partner authority areas as a resultof the following reasons listed below:

Are you in full-time employment in the area?

If yes please provide full details, including employer’s name, address and telephonenumber:

Are you attending a college or training establishment in thearea?


Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

10

Have you lived in any of the partner local authority areas for either:

If yes please provide full details, includingname and address of the college/training establishment, the dateand course details:

Do you have a close familyconnection in the area orhave family or friends who will give or need your support?

If yes please provide fulldetails, including thename and address of thefamily member(s) orfriends who will eitherprovide or will need yoursupport, and their relationship to you:

Please give the reasons forneeding or providing thissupport:

• Six of the last 12 months

• Three of the last five years

If yes please provide details, including the fulladdress and dates:

Have you ever served withthe armed forces and previously had a local connection with any of thepartner local authorities?


GatesheadNewcastleNorth TynesideSouth TynesideSunderland

Please choose:GatesheadNewcastleNorth TynesideSouth TynesideSunderland

Please choose:

11

Yes No Yes No

Section 4 - Other household members

Please complete details of your household below:

Full name Date of Gender Relationship Nationality Ethnic origin Are they to be birth to you rehoused with you?

If yes please provide details of the address, andthe approximate dates andreasons:

Would you consider rehousing in more thanone local authority area?

If yes which?


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Please provide details of anyone who is not currently living with you but will bewhen you move:

Please provide details of any children under the age of 16 who do not live with younow but stay with you on a regular basis:

Full name Date of Gender Relationship Nationality Ethnic Current Tenure (if council birth to you origin address please state which)

Full name Date of Gender Relationship Nationality Ethnic Current How often do they birth to you origin address stay with you?

13

Please provide any addresses of household members over 16 who are to be rehoused with you, if at any time they lived somewhere different from above:

Address Landlord (if applicable) Date from Date to Reason for leaving

Household member


Housing history

Please provide details of all addresses you have lived in during the last five years,other than your current home.

Main applicant


Joint applicant

Is anyone in your household pregnant, other than previously mentioned?If yes, you may need to provide a MAT B1 form or letter from your doctor.

Yes No

14

What kind of tenancy, ifany, do you have?

Landlord name (if applicable)

Landlord address

Landlord telephone number

Landlord e-mail address


Section 5 - Current home

Asylum seeker serviceBed and breakfast/hostelCaravanCouncil/local authorityEmergency accommodationHM ForcesHousing associationsIn hospital or long-termcareLiving in with familyLiving in with friendsNo fixed accommodationOwner occupierPrivate landlordRelationship breakdownbut in family homeResidential careSleeping rough Supported accommodationTied accommodation provided by employerOther (please state)

Please choose:

Asylum seeker serviceBed and breakfast/hostelCaravanCouncil/local authorityEmergency accommodationHM ForcesHousing associationsIn hospital or long-termcareLiving in with familyLiving in with friendsNo fixed accommodationOwner occupierPrivate landlordRelationship breakdownbut in family homeResidential careSleeping rough Supported accommodationTied accommodation provided by employerOther (please state)

Please choose:

15

Have you or any memberof your household servedin any of the armed forces?

If yes, who?

Approximate dischargedate:

What kind of property doyou currently live in?

If a flat, which floor is iton?

Is the main entranceshared with anotherhousehold?

Is there a lift in the building?


BungalowCaravan/mobile homeCommunal entrance flatCommunal entrancemaisonette (lower)Communal entrancemaisonette (upper)CottageGround-floor flatGround-floor maisonetteHouseLower bedsitMulti-storey flatSheltered flat lowerSheltered flat upperSupported housingUpper bedsitUpper flatUpper maisonette

Please choose:BungalowCaravan/mobile homeCommunal entrance flatCommunal entrancemaisonette (lower)Communal entrancemaisonette (upper)CottageGround-floor flatGround-floor maisonetteHouseLower bedsitMulti-storey flatSheltered flat lowerSheltered flat upperSupported housingUpper bedsitUpper flatUpper maisonette

Please choose:

Yes No Yes No

Yes No Yes No

Yes No Yes No

16

How many bedrooms intotal are there in yourproperty?

How many bedrooms doyou have available to you?

How many of these aredouble?

How many of these aresingle?

Are any unoccupied?

Which, if any, does yourhome not have?

Which if any of the abovefacilities do you share withanother household?

Do you have pets?

If yes, what type and howmany?


Bedsit12

345+

Please choose:Bedsit12

345+

Please choose:

Bedsit12

345+

Please choose:Bedsit12

345+

Please choose:

None12

345+

Please choose:None12

345+

Please choose:

BathFull central heatingHot waterIndoor WCCentral heatingPartial central heatingKitchenBathroom

Please choose:BathFull central heatingHot waterIndoor WCCentral heatingPartial central heatingKitchenBathroom

Please choose:

Yes No Yes No

Yes No Yes No

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Section 6 - Your requirements

What is your main reasonfor wanting rehousing?*(please see key on nextpage.)


Access to childrenApproved to adopt s

Approved to foster s

Asked to leave ss

Child under 16 in upper flatDemolition or regeneration ss

Discharge from armed forces ss

Dislike of propertyDomestic violence or abuseEviction or NTQ order ss

Fire/floodHarassmentHomeless (actual) ss

Homeless (threatened) ss

Hospital dischargeKey worker ss

Leaving care ss

Leaving supported accommodation ss

Loss of tied accommodation ss

Nearer to hospital for treatmentNearer to relatives/friendsNearer work/training/school sss

No specific reason/choicePrison discharge ss

Problems with neighboursProblems with the areaProperty in poor conditionProperty too largeProperty too smallProperty unsuitable due to ill healthRacial harassmentRelationship breakdown -non violentTo give or receive support sss

Unable to afford

Please choose:Access to childrenApproved to adopt s

Approved to foster s

Asked to leave ss

Child under 16 in upper flatDemolition or regeneration ss

Discharge from armed forces ss

Dislike of propertyDomestic violence or abuseEviction or NTQ order ss

Fire/floodHarassmentHomeless (actual) ss

Homeless (threatened) ss

Hospital dischargeKey worker ss

Leaving care ss

Leaving supported accommodation ss

Loss of tied accommodation ss

Nearer to hospital for treatmentNearer to relatives/friendsNearer work/training/school sss

No specific reason/choicePrison discharge ss

Problems with neighboursProblems with the areaProperty in poor conditionProperty too largeProperty too smallProperty unsuitable due to ill healthRacial harassmentRelationship breakdown -non violentTo give or receive support sss

Unable to afford

Please choose:

18

Section 7 - Employment and financial information

•s If you have indicated that you have been approved to adopt or foster children then you will need to provide supporting documents.

• If you have chosen any of the values marked with ss then you need to provide therelevant date

• If you have chosen any of the values marked with sss then you need to provide thename and address of the employer, training facility/school or person you are supporting

What type of propertywould you like?

How many bedroomswould you like?


At present are you:*


Please choose:

Full-time employmentFull-time studentIn receipt of state pensionLong-term illness and unable to workOn government training schemePart-time employment (less than 20 hours)Self-employedUnemployed and seeking employmentWorking from homeOther

Please choose:

Full-time employmentFull-time studentIn receipt of state pensionLong-term illness and unable to workOn government training schemePart-time employment (less than 20 hours)Self-employedUnemployed and seeking employmentWorking from homeOther

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Are you in receipt of anystate benefits (please tickall that apply)?

Job title (if applicable)

Employer name

Employer address

What is your estimatedgross annual income?*

Have you any savings?

If yes, how much?

Have you, or any memberof your household who isto be rehoused with you,any outstanding rent arrears, chargeable repairsor other housing relateddebt on your current orprevious home?


Please choose:

Attendance AllowanceBereavement BenefitCarers AllowanceChild BenefitChild Tax CreditsIn receipt of AttendanceAllowance Higher RateIn receipt of AttendanceAllowance Lower Rate In receipt of DLA Higher RateIn receipt of DLALower RateIncapacity BenefitIncome SupportJob Seekers AllowancePension CreditSevere Disability AllowanceState Retirement PensionWidow/Widower BenefitWorking Tax Credits

Attendance AllowanceBereavement BenefitCarers AllowanceChild BenefitChild Tax CreditsIn receipt of AttendanceAllowance Higher RateIn receipt of AttendanceAllowance Lower Rate In receipt of DLA Higher RateIn receipt of DLA Lower RateIncapacity BenefitIncome SupportJob Seekers AllowancePension CreditSevere Disability AllowanceState Retirement PensionWidow/Widower BenefitWorking Tax Credits

Please choose:

Yes No Yes No

Yes No Yes No

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What other housing options would you consider?


Main applicant Joint applicant Household member(please provide name)

Who:

Name:

Address with debt attached:

Landlord,bank or financialprovider:

Amount:

Have you, or anyone named on your application who is to be rehoused with you, currently own or has owned a property,including any property overseas, in the last five years?

If yes, please provide an estimate ofits value or how much it was sold for:

If yes, how much was or isoutstanding?

Please choose:

Extra care accommodationIntermediate rentingLocal authority rentedLow cost home ownershipMarket rentedMutual exchangeNo otherPrivate rented sectorRegistered social provider(housing association)Shared ownershipSupported housing

Please choose:

Extra care accommodationIntermediate rentingLocal authority rentedLow cost home ownershipMarket rentedMutual exchangeNo otherPrivate rented sectorRegistered social provider(housing association)Shared ownershipSupported housing

If yes, please provide details:

Is it or was it subject to a mortgage? Yes No

Yes No

21

Section 8 - Other services

The partner organisations would like to keep you informed of other products andservices that may be of interest to you.

Would you like to receive information on additional Yes Noproducts or services?

If you would like to receive such information by e-mail or text message, please ensure you have provided up-to-date contact details.

Several of the partner organisations provide additional services, for example community care and warden services, to help people to either remain in their ownhomes, live confidently and independently in their new home or provide other housing options.

Do you agree for your personal details to be provided to the appropriate service if it is considered that such support Yes No would benefit you?

Section 9 - Medical assessment

This section is optional and should only be completed if you feel that your, or anymember of your household's, health is affected by your housing situation.

Please note a further assessment may be required before any additional awardcan be given.

Please choose:Occasional use of a walking aidPermanent use of a walking aidUse a wheelchair on occasions (outdoors only)Use a wheelchairpermanently

Occasional use of a walking aidPermanent use of a walking aidUse a wheelchair on occasions (outdoors only)Use a wheelchairpermanently

Please choose:

Please choose:Downstairs bathroomDownstairs WCOutside WCUpstairs bathroomUpstairs WCWC on both upper andground floor

Downstairs bathroomDownstairs WCOutside WCUpstairs bathroomUpstairs WCWC on both upper andground floor

Please choose:

Do you or anyone to be rehoused with you use orneed

Are there steps to yourmain access door?

If yes, how many?

Where are the bathroomand toilet facilities in yourhome?


Yes No Yes No

Please choose:

Only with the support ofadaptationsUnable to manageWith easeWith significant difficultyWith some difficulty


Please choose:

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Please choose:

Ceiling hoist and trackClosomat WCGrab railsKitchen adaptationsLevel-access showerRaised sockets and lowerlight switchesRamped accessShower over bathStairliftThrough the floor liftWidened doors

Ceiling hoist and trackClosomat WCGrab railsKitchen adaptationsLevel-access showerRaised sockets and lowerlight switchesRamped accessShower over bathStairliftThrough the floor liftWidened doors

Please choose:

Yes No Yes No

Yes No Yes No

Has your home beenadapted for you or anyonein your household with

Would any be required onrehousing?

If yes, which:

Would you be able to remain in your presenthome if any adaptationswere carried out?

If yes, which:

Do you or anyone wantingto be rehoused with youhave the ability to managethe stairs in your home (if applicable)?


Please choose:



Please choose:

Please choose:



Please choose:

Please choose:



Please choose:

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Yes No Yes No

Do you or anyone wantingto be rehoused with youhave the ability to managethe stairs outside yourhome?

Do you or anyone wantingto be rehoused with youhave the ability to managethe bathing facilities inyour home?

Do you or anyone wantingto be rehoused with youhave the ability to managethe WC facilities in yourhome?

Are you prevented fromaccessing any of the mainareas in your home?

Further details if morethan one household member affected:


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Data protection

Tyne and Wear Homes is a partnership comprising of Gateshead Council and TheGateshead Housing Company; Newcastle City Council and Your Homes Newcastle;North Tyneside Council and North Tyneside Homes; South Tyneside Council andSouth Tyneside Homes; and Sunderland City Council and Gentoo.

This partnership may be extended to include other active registered social landlords across the partnership area, provided that they comply with the standards agreed.

The information that you have provided will enable a partner of Tyne and WearHomes to process your application and determine an outcome in accordance withlegislation and relevant Lettings Policy.

The information you have provided will be held safe and securely on both computerised and manual files. The data will only be accessible to those partnersinvolved in the scheme who have a requirement to process your application andconsider the allocation of a property to you.

Information given in this application may be shared with other bodies for the prevention of crime, including fraud. Unless otherwise stated, the informationwill only be used for the purposes of housing services.

By signing this declaration you confirm that you have read and understood thissection. In order to make sure you are aware of all of the services available to youas a member of Tyne and Wear Homes, partners of the scheme may wish to contact you from time to time.

• If you don't want to receive this information by post or telephone please tick here

• If you would like to receive this information by e-mail or text, please tick here

Please ensure you have provided your current contact details on this applicationform.

Declaration

I understand that it is an offence to give false information or to withhold any information relevant to my application, and to do so could make me liable for amonetary fine.

I understand that should the tenancy be granted based on false or withheld information by me or anyone acting on my behalf, the partners will reserve theright to recover the possession of any property that has been allocated.

I understand that Tyne and Wear Homes may need to make enquiries about mycharacter and the conduct of any current or previous tenancy. I therefore authorise Tyne and Wear Homes to make enquiries with the police, probationservices, doctors, health professionals, present or previous landlords, or any support agency to obtain any relevant information in relation to my application.

I understand that it is my responsibility to notify the partnership of any change inmy circumstances that may affect my application.

I understand that the information given in this form may be passed on to all landlords participating in the Tyne and Wear Homes scheme, along with otheroutside agencies where legally required.

I confirm that I have completed this application accurately to the best of myknowledge and confirm that any information given either by me or any personacting on my behalf is true and accurate.

Print name: (Joint applicant)

Print name:

Signature: Signature:

Date: Date:

25

Your Homes Newcastle

6 - 8 Saville Row, Newcastle upon Tyne, NE1 8JE

Tel: 0191 277 2020

E-mail: [email protected]

Web: www.yhn.org.uk

Newcastle City Council

Civic Centre, Barras Bridge, Newcastle upon Tyne, NE99 2BN

Tel: 0191 232 8520 Visit: www.newcastle.gov.uk

26

Contact information

Thank you for completing your application for Tyne and Wear Homes.

For further information on Tyne and Wear Homes, contact any of the housingorganisations below:

The Gateshead Housing Company

Keelman House, Fifth Avenue Business Park, Fifth Avenue, Team ValleyTrading Estate, Gateshead, NE11 0XA

Tel: 0191 433 5345


Visit: www.gatesheadhousing.co.uk

Gateshead Council

Civic Centre, Regent Street, Gateshead, NE8 1HH

Tel: 0191 433 3000 Visit: www.gateshead.gov.uk

Homes in Gateshead

Homes in Newcastle

27

North Tyneside Homes

North Tyneside Homes, Quadrant, West 2nd floor, The SilverlinkNorth, Cobalt Business Park, North Tyneside, NE27 0BY

Tel: 0345 2000 102


Visit: www.northtyneside.gov.uk

North Tyneside Council

Quadrant, The Silverlink North, Cobalt Business Park, North Tyneside, NE27 0BY

Tel: 0345 2000 101 Visit: www.northtyneside.gov.uk

Homes in North Tyneside

South Tyneside Homes

Strathmore, 11 Rolling Mill Road, Viking Business Park, Jarrow, NE32 3DP

Tel: 0300 123 6633


Visit: www.southtynesidehomes.org.uk

South Tyneside Council

Town Hall and Civic Offices, Westoe Road, South Shields, Tyne and Wear, NE33 2RL

Tel: 0191 427 1717 Visit: www.southtyneside.info

Homes in South Tyneside

Gentoo Group

Emperor House, 2 Emperor Way, Doxford International BusinessPark, Sunderland, SR3 3XR

Tel: 0191 525 5000


Web: www.gentoogroup.com

Sunderland Council

Allocations Team, Independent Living Centre, Claymere Road,Leechmere Industrial Estate, Sunderland, SR2 9TQ

Tel: 0191 520 5523


Web: www.sunderland.gov.uk

Homes in Sunderland

TWH-application-form-Dec 2011

and Wear Homes Housing application - South Tyneside

Documents

Transcript of and Wear Homes Housing application - South Tyneside