HOUSING APPLICATIONPlease use block capitals when completing this form and provide as much information as possible as this will help us to assess your points accurately. You will need to complete every question that applies to you otherwise your application may be rejected. Please note that before you start your application you will need your National Insurance number, your address history for the last five years and, if applicable, your landlord's contact details for your current and previous addresses. Further details on our housing allocation scheme can be found on our website at www.harrogate.gov.uk. If you need any advice or help to complete this form please contact Customer Services on 01423 500600.

OFFICE USE ONLY

Date received: Acknowledged:

Date logged:

Inputting Officer: Application No:

Personal details

BOROUGH COUNCIL

Harrogate

Q1 Main applicant

Mr/Mrs/Miss/Ms (please delete)

Last name

First name(s)

Date of birth / /

Your current address or a contact address

PostcodeYour contact telephone number

Email address

National Insurance number

Gender: Male/Female/Other (please delete)

Next of kin

Name

Telephone

Q2 Joint applicant

Mr/Mrs/Miss/Ms (please delete)

Last name

First name(s)

Date of birth / /

Please tell us your relationship to the main applicant, for example, spouse, partner.

Your current address or a contact address

PostcodeYour contact telephone number

Email address

National Insurance number

Gender: Male/Female/Other (please delete)

Next of kin

Name

Telephone

Q7 IsEnglishyourfirstlanguage?

Main applicant Yes No

If no, please tell us what your first language is.

Joint applicant Yes No

If no, please tell us what your first language is.

Q6 Which of the following best describes how you think of yourself?

Main Joint applicant applicant

Bisexual

Gay man

Heterosexual/straight

Gay woman/lesbian

Other

Prefer not to say

Q3 Details of your relationship status (please tick):

Main Joint applicant applicant

Single

Married/Civil Partnership

Partner

Separated

Divorced

Co-habitee

Widow

Widower

Do not wish to declare

Q4 Your ethnicity (please tick):

Main Joint applicant applicant

Asian or Asian British Bangladeshi

Asian or Asian British Indian

Asian or Asian British Pakistani

Asian or Asian British other

Asian

Bangladeshi

Black or Black British African

Black or Black British Caribbean

Black or Black British other

Black African

Black Caribbean

Black other

Chinese

Gypsy Roman Traveller

Indian

Mixed other

Mixed White Asian

Mixed White and Black Caribbean

Mixed White and Black African

Pakistani

White

White British

White other

Other

Do not wish to declare

Q5 Please enter your religion: Main Joint applicant applicant

Buddhist

Christian

Hindu

Jewish

Sikh

Muslim

Other

No religion

Prefer not to say

Q8 Do you need this information translatedintoanotherlanguage?

Yes No

If yes, what language do you want this translating into?

We want to shape our housing service to meet the needs of our customers and to make sure that everyone is treated fairly and able to access the service as easily as possible. Questions 3 to 9 are not compulsory but the information you provide will help us to do this.

Q9 Does anyone in the household have a disabilityundertheEqualityAct?

Yes No

The definition of a disability according to the Equality Act 2010 is: “A physical or mental impairment which has a substantial and long-term adverse effect on his or her ability to carry out normal day to day activities”. Long-term means more than 12 months. The definition covers long-term illnesses such as cancer and HIV or mental health; it includes any adult or child living permanently in the household.

If you answered 'yes' to the previous question please answer the further questions about disability below. If you would prefer not to answer these questions, please leave them blank. However, if you are happy to answer them please put a tick against each one that applies.

Physical disability

Visual impairment

Speech impairment

Hearing impairment

Mental health problems

Long term illness

Difficulties reading or writing

Learning disability

Disability not listed above

Please give details here

Prefer not to say

Household personal details (other adults)Q10 Please give details of everyone

who needs housing with you.

Mr/Mrs/Miss/Ms (please delete)

Last name

First name(s)

Date of birth

National Insurance number

Gender: Male/Female/Other (please delete)

Relationship to you for example mother, son.

Mr/Mrs/Miss/Ms (please delete)

Last name

First name(s)

Date of birth

National Insurance number

Gender: Male/Female/Other (please delete)

Relationship to you for example mother, son.

If you need to list more adults who need housing with you, please use the space provided in the 'Additional Information' section on the back page.

Household personal details (children)Q11 Please give details of children who

need housing with you.

Last name

First name(s)

Date of birth

Gender: Male/Female/Other (please delete)

Relationship to you for example son, daughter.

Do you receive child benefit for them? Yes No

Last name

First name(s)

Date of birth

Gender: Male/Female/Other (please delete)

Relationship to you for example son, daughter.

Do you receive child benefit for them? Yes No

Last name

First name(s)

Date of birth

Gender: Male/Female/Other (please delete)

Relationship to you for example son, daughter.

Do you receive child benefit for them? Yes No

If you need to list more children who need housing with you, please use the space provided in the 'Additional Information' section on the back page.

Main applicant addresses Q12 Starting with your current address, please tell us where you have lived over thelastfiveyearsandwhoownedtheproperty, for example private landlord, council, housing association, parents. If you arecurrentlyofnofixedabode,youmustprovide a correspondence address.

Property OneAddress

Date from / / Date to / /

What is the landlord’s name and address?

Landlord's contact number/email

If not renting, what are your circumstances, for example lodging, owner-occupation.

Property TwoAddress

Date from / / Date to / /

What was the landlord’s name and address?

Landlord's contact number/email

If not rented, what were your circumstances, for example lodging, owner-occupation.

Why did you leave?

Q14 Ifyouarecurrentlyofnofixedabode,or lodging with family/friends on a temporary basis, please provide details of any rent arrears you accrued at your last settled address.

Q15 Have you or anyone included in this application ever had a tenancy in a Harrogate Borough Council property that is not your current property or a propertyalreadymentioned?

Yes No

If yes, please provide details

If you need to list more properties, please use the space provided in the 'Additional Information' section on the back page.

Property ThreeAddress

Date from / / Date to / /

What was the landlord’s name and address?

Landlord's contact number/email

If not rented, what were your circumstances, for example lodging, owner-occupation.

Why did you leave?

Property FourAddress

Date from / / Date to / /

What was the landlord’s name and address?

Landlord's contact number/email

If not rented, what were your circumstances, for example lodging, owner-occupation.

Why did you leave?

Q13 If you are liable for rent in your current property,areyouinrentarrears?

Yes No

If Yes, please provide details.

Property OneAddress

Date from / / Date to / /

What is the landlord’s name and address?

Landlord's contact number/email

If not renting, what are your circumstances, for example lodging, owner-occupation.

Property TwoAddress

Date from / / Date to / /

What was the landlord’s name and address?

Landlord's contact number/email

If not rented, what were your circumstances, for example lodging, owner-occupation.

Why did you leave?

Property ThreeAddress

Date from / / Date to / /

What was the landlord’s name and address?

Landlord's contact number/email

If not rented, what were your circumstances, for example lodging, owner-occupation.

Why did you leave?

Property FourAddress

Date from / / Date to / /

What was the landlord’s name and address?

Landlord's contact number/email

If not rented, what were your circumstances, for example lodging, owner-occupation.

Why did you leave?

Joint applicant addresses Please provide this information if the address history differs from that of the main applicant.

Q16 Starting with your current address, please tell us where you have lived over thelastfiveyearsandwhoownedtheproperty, for example private landlord, council, housing association, parents. If you arecurrentlyofnofixedabode,youmustprovide a correspondence address.

If you need to list more properties, please use the space provided in the Additional Information section on the back page.

Q17 If you are liable for rent in your current property,areyouinrentarrears?

Yes No

If Yes, please provide details

Q18 Ifyouarecurrentlyofnofixedabode, or lodging with family/friends on a temporary basis, please provide details of any rent arrears you accrued at your last settled address.

Q21 What is your local connection to thedistrict?

Our local connection criteria is explained on our website www.harrogate.gov.uk/localconnection in the housing allocation scheme summary information booklet.

In addition to your five year address history detailed in questions 12 and 16, please provide any additional local connection details (for example name, address, relevant dates of residency/employment).

Previous resident - this applies if you have previously lived in the district for a continuous period of ten years.

Family who live in the area (please give full details of their names, addresses, relationship to you and how long they have lived in the Harrogate district).

Your current employment details.

Your current circumstances

Q20 Inthepastfiveyears,ifyouoranyone moving with you have come to live in the UK or returned to the UK from living abroad, please provide their name, the country they entered the UK from, and the date they entered the UK.

Q19 If you or any of the people moving with you are not UK citizens, please providedetailsandconfirmwhichcountry they are a citizen of.

Q22 Are you a current or former member of the Reserves/Armed Forces serving atanytimeinthefiveyearsprecedingyourapplicationforhousing?

Please give details of length of service and service personnel number.

Q23 Are you a bereaved spouse or civil partner who can no longer live in Ministry of Defence accommodation following the death in service of yourspouseorpartner?

Please give details

Q24 Are you a social housing tenant living in England, needing to move into the district to take up an offer of employment?

Please provide details

Q25 Does any member of the household ownapropertyanywhereintheworld?

Yes No

Q26 Is the combined household income morethan£60,000peryear?

Yes No

Q27 Are the combined household savings morethan£120,000?

Yes No

Q28 Are you or any of these people to be rehousedwithyouexpectingababy?

Yes No

If yes, please state their name and when the baby is due.

Q29 Doyouhaveanypets?

Yes No

If yes, please give details.

Q30 Medical factors

Please give details of yourself and anyone wishing to be housed with you who is suffering from a serious illness or disability that is affected by your accommodation.

First Person

Last name

First name(s)

Name and address of doctor

Name of occupational therapist (if applicable).

Details of illness / disability and reasons why your current accommodation is no longer suitable.

Second person

Last name

First name(s)

Name and address of doctor

Name of occupational therapist (if applicable).

Details of illness / disability and reasons why your current accommodation is no longer suitable.

If there are any other people with a medical condition, please give details in the 'Additional Information' section on the back page.

Q32 Details of any convictions.If you or anyone included in this application has ever been convicted of a criminal offence, or been involved in any inappropriate activity, such as anti- social behaviour, please give details.

Name

Date of offence(s)

Details

Your current homeQ33 What type of home do you

liveinnow?(Please tick)

House

Flat

Bungalow

Maisonette

Mobile home size

Bed and breakfast

Bedsit

Shared House

Hostel

Other (please specify)

(specify feet or metres)

Q34 What floor is your current accommodationon? (Please tick)

Ground First Second

Other (please specify)

Q35 What type of amenities doyouhave? (Please tick) Yes No

Living room

Separate kitchen

Separate bathroom

Inside toilet

Hot water supply

Cold water supply

Q36 Do you share any of these rooms with someone NOT beingrehousedwithyou? (Please tick) Yes No

Living room

Dining room

Kitchen

Bathroom

Toilet

Q31 Is there anyone who you would like to support your application - such as a social worker or care assistant, or a friend or relative who provides careorsupport?

Please give their full name, address and contact telephone number.

Do you think you will need additional support if we are able to offer you accommodation, for example budgeting, or understanding correspondence?

Q41 If you have been asked to leave your present accommodation please give details.

Please provide written proof.

What is the date you have to leave by?

Who asked you to leave?

Why do you have to leave?

About the home you want

Q42 What type of home do yourequire? (Please tick)

House

Bungalow

Maisonette

Bedsit - ground floor only

Bedsit - any floor

Flat - ground floor only

Flat - any floor

Please state your reasons for applying.

Q43 Do you require adapted accommodation?

(Please tick) Yes No

Level access shower

Full wet room

Ramped access

Fully wheelchair accessible

Stair lift

Through floor lift

Grab rails for bathing or toileting

Grab rails - other

Multiple adaptations

Q44 Does any member of your household need their own bedroom for medical reasons?

Yes No

If yes, please specify who and why.

Q37 How many bedrooms are there in yourhome? (Please tick ‘Single’ or ‘Double’ and whether it is for you/your family’s 'Sole Use')

Single Double Sole Use Bedroom 1

Bedroom 2

Bedroom 3

Bedroom 4

Q38 Do you have a garden/enclosed yard?

Yes No

Q39 Is your home in a poor state ofrepair?

Yes No

If ‘yes’ please give details?

Q40 What is your current accommodation type? (Please tick)

Secure tenancy

Assured Shorthold tenancy

Assured Shorthold tenancy with notice to quit (Section 21 Notice)

Assured tenancy - housing association

Hospital and no other accommodation

Lodger

Owner-occupier

In prison and due for release

Living with relative/friends

Sleeping rough

Tied accommodation

Temporary accommodation

Other

3 Ripon 03010 Lead Lane

03020 Holmefield

03S17 Russell Dixon Square

03030 Northern

03040 Central

4 Boroughbridge 04270 Cundall

04460 Skelton-on-Ure

04470 Kirby Hill

04630 Roecliffe

04640 Boroughbridge

04S24 Springfield, Boroughbridge

0464L Langthorpe

0464M Minskip

5 Knaresborough Villages 05101 Goldsborough

05102 Flaxby

05700 Staveley

05780 Arkendale

05830 Scotton

05850 Ferrensby

Location choicesQ45 You are able to choose the location of your preferred accommodation, although YOU MUST CHOOSE A MINIMUM

OF FOUR out of the sixteen main lettings areas across the Harrogate district and one of those areas must include either Harrogate, Knaresborough or Ripon. If you don't choose four areas, your application will be rejected. Please indicate the four or more areas you would like to be considered for by ticking the boxes below. Please refer to the map showing the letting areas. It is advisable to widen your choice as much as possible, but for more rural areas please check the availability of facilities such as public transport before making your choices. You will receive a maximum of two offers of accommodation. You may select up to 16 areas. THIS DOESN'T APPLY IF YOU ARE SPECIFICALLY INTERESTED IN SHELTERED HOUSING. PLEASE SEE Q46 FOR MORE INFORMATION ON SHELTERED HOUSING AND THE INDEPENDENT LIVING SERVICE.

1 Harrogate 01011 Harewood Newby Bramham Markenfield

01012 Lichfield Norwich Lincoln

01013 Harlow/Otley Road (housing association)

01020 Oakdale

01S06 Alder Road

01031 Woodfield

01S07 Woodfield Square

01032/01S05 Dene Park

01033 County

01034 Skipton Road

01035 New Park

01036 High Harrogate/ Devonshire (housing association)

01041 St Andrews

01042 Fairfax Walworth Cawthorn

01S03 Fairfax Avenue

01S04 Wedderburn Road

01043 Eleanor & Wetherby Road

01044 Knaresborough Road Hospital Site (housing association)

01045 Forest Moor (housing association)

01050 Starbeck

01S01 Station View

01S02 Spa Mews

01060 Central

01070 Oatlands/Pannal/ St Georges/Boulevards (some are housing association)

7 Lower Wharfedale 07121 Follifoot

07122 Little Ribston & Spofforth

07135 North Deighton

07136 Kirk Deighton

07141 Kirkby Overblow

07149 Sicklinghall

8 Upper Wharfedale 08106 Fewston

08107 Norwood

08131 Askwith

08140 Newall with Clifton

9 Lower Nidderdale 0961S Shaw Mills

0961T Bishop Thornton

09820 Nidd

09910 Birstwith

09920 Hampsthwaite

09930 Killinghall

2 Knaresborough & Scriven

02010 Briggate

02S09 Windsor Lane

02030 Stockwell

02S13 Stockwell Grove

02040 Inman

02050 Central

02060 Charlton

02S14 Charlton Drive

02070 Manor

02S12 Manor Court

02940 Scriven

6 Vale of York 06102 Marton-cum-Grafton

06103 Green Hammerton

06104 Nun Monkton

06110 Hunsingore

06113 Kirk Hammerton

06115 Moor Monkton

06720 Lower Dunsforth

06800 Great Ouseburn

06880 Little Ouseburn

06960 Whixley

13 Marston Villages 13001 Tockwith

13002 Long Marston & Hutton Wandesley

13003 Bilton in Ainsty & Bickerton

13004 Wighill

14 Northern Villages 14001 Baldersby

14002 Wath

14003 Melmerby

14004 Hutton Conyers

14005 Nunwick

14006 Rainton

14007 Asenby

14008 Dishforth

14009 Sharow

14010 Copt Hewick

14011 Marton-le-Moor

14012 Bridge Hewick

15 Ripon South Villages 15001 Markington

15002 Bishop Monkton

15003 Burton Leonard

15004 South Stainley

16 Ripon West Villages 16001 North Stainley

16003 Kirkby Malzeard

16S19 Mowbray Crescent & High Street, Kirkby Malzeard

16004 Winksley

16005 Sawley

16006 Littlethorpe

Please check the map below for the location of your chosen

area

12 Pannal Villages 12001 Beckwithshaw

12002 North Rigton

12003 Weeton & Huby

12S23 Kingsway, Weeton

11 Masham Area 11030 Masham

10 Upper Nidderdale 10170 Lofthouse

1049G Glasshouses

10S21 Lupton Close, Glasshouses

1049P Pateley Bridge

10S20 Nidd Walk & Southlands, Pateley Bridge

10S25 Netherdale, Pateley Bridge

10660 Summerbridge

10900 Darley

10S22 Valley Road, Darley

Map of Harrogate DistrictShowing Letting Areas(see stock list for further details)

MASHAM

Lofthouse

Summerbridge

Killinghall

PATELEY BRIDGE

RIPON

Melmerby

Baldersby St James

Bishop Monkton

Burton Leonard

Staveley

HampsthwaiteBirstwithDarley

Beckwithshaw

Spofforth

Great Ouseburn

Tockwith

Minskip

Sawley

Winksley

Kirkby MalzeardNorth Stainley

Wath

Bishop ThorntonShaw Mills

Scotton

Arkendale Little Ouseburn

Glasshouses

Markington

Flaxby

DunsforthsMarton cum Grafton

RaintonHutton Conyers

Sharow DishforthCopt Hewick

SkeltonKirby HillLangthorpe

BOROUGHBRIDGE

WhixleyGreen Hammerton

Kirk HammertonKNARESBOROUGH

HARROGATEGoldsborough

Hunsingore

Long Marston

AskwithSicklinghall

Little Ribston

North DeightonKirk Deighton

Bickerton

Wighill

North Rigton

HubyWeeton Kirkby Overblow

Newall with Clifton

Bilton in Ainsty

13

11

10

15

14

12

9

8 7

12 65

4

3

1. Harrogate2. Knaresborough & Scriven3. Ripon4. Boroughbridge5. Knaresborough villages6. Vale of York7. Lower Wharfedale8. Upper Wharfedale9. Lower Nidderdale villages10. Upper Nidderdale11. Masham area12. Pannal villages13. Marston villages14. Northern villages15. Ripon south villages16. Ripon west villages

16

© Crown copyright and database rights 2015 Ordnance Survey 100019628.

Ilkley

Otley

ConnectionsQ47 Employees of housing providersDo you, or anyone in your household, or anyone related to you, work for any of the housing providers you have applied to? Yes No

If ‘yes’ please give their name and who they work for:

Q48 Elected member or members of staff

Are you, or any member of your household, related to any Harrogate Borough Council elected member, or member of staff? Yes No

If ‘yes’ please give their name and relationship to you:

Name of relative

Relationship to you

Independent Living ServiceQ46 The council has six sheltered housing schemes of purpose built flats with an emergency call system for people aged 60 or older who are still able to live independently, but who would benefit from the security and the support of an Independent Living Officer.

These schemes are Carlton Lodge - Harrogate; Collins Court and Hewitson Court - Knaresborough; Bondgate Court and Blossomgate Court - Ripon and Maple Creek - Masham.

Sheltered Housing Schemes

01S08 Carlton Lodge 02S11 Collins Court

02S10 Hewitson Court 11S18 Maple Creek

03S15 Bondgate Court 03S16 Blossomgate Court

Harrogate Lifeline ServiceWe also offer an Independent Living Support service for anyone aged 60 years or older. This is available to anyone - social housing tenants, homeowners or those renting privately. Support is provided by an Independent Living Officer, via a Lifeline unit using the property's telephone land line. To be considered for either our sheltered housing accommodation or Harrogate Lifeline Service you will be asked to complete a needs assessment to identify your particular needs and the support you require. Although both these types of support are principally for people aged 60 years or older, we also consider other vulnerable people subject to a support needs assessment.

If you are interested in Older Persons Independent Living Support Service and you need some additional support, please provide brief details of your needs in the 'Additional Information' section on the back page.

HomeSwapper Mutual Exchange ServiceIf you are an existing social housing tenant we recommend that you register for a home swap at www.homeswapper.co.uk

DeclarationQ49 Please read this declaration carefully and then sign it. If you are applying

jointly, you both need to sign it. To find out what your rights are please go to our website www.harrogate.gov.uk/privacynotice

I/we consent to the council obtaining/releasing information to other landlords/landlords’ agents/professional housing organisations/government agencies/medical professionals if necessary relating to my/our application.

I/we explicitly consent for North Yorkshire Police to disclose details of my/our previous criminal convictions, any risk assessments they have carried out, or agencies they know to have carried out risk assessments in relation to me/us; also, any information that the police may have relevant to future crime prevention and community safety issues relating to me/us to Harrogate Borough Council for the purpose of permitting them to manage any risk, and reduce potential for future re-offending.

I/we understand that the information contained on my/our application may be released to the Audit Commission in respect of the National Fraud Initiative to detect fraud against the public purse and the council may share this information for the same purposes with other organisations that handle public funds.

I/we understand that if I/we have come to live in this country within the last five years, the council may have to approach the Home Office to check the information I/we have given in this form and to obtain further related information.

I/we understand that legal action may be taken against any person who obtains accommodation as a result of giving false or misleading information or withholding information which has been requested.

I/we will inform the council in writing if my/our circumstances change.

Applicant’s signature Date

Joint Applicant’s signature Date

Please use this space to note any additional details to support your application.

Please return this form to: Housing and Property, Harrogate Borough Council, PO Box 787, Harrogate, HG1 9RW.

HBC MAR2018 JS