Salvation Army Housing Association Housing Application

For help in completing this form, please contact the Customer Services Centre (Tel: 0800 970 6363)

Scheme/Project applying for:______________

______________________________________

Please complete all the questions. We will not be able to process you application otherwise.

PERSONAL DETAILS

Applicant’s name (Mr, Mrs, Miss, Ms) __________________________________________________Address ___________________________________________________________________________________________________________________________ Postcode _____________________Telephone number (daytime) __________________________ (evening) ____________________ (mobile) _____________________ email address ________________________Next of kin _________________________________________Telephone number ______________Contact address if different from above ________________________________________________National Insurance number _________________________________________________________Are you related to an employee/member of the Salvation Army Housing Association? If yes, who? _____________________________________________________________________Have you ever been cautioned or convicted of a criminal offence? Yes NoIf yes, please give details of all offences and dates_______________________________________Has the conviction been spent? Yes NoPlease give details of any current probation or other kind of community order. Include any current or previous bail conditions___________________________________________________________

YOUR HOUSING NEEDS

TYPE OF ACCOMMODATION APPLYING FOR

Elderly 60+

Single Person/Couple

Family

Accommodation With Support

Foyer

Supported Scheme

WHO NEEDS TO BE REHOUSED?Please give details of everyone who needs to be re-housed, starting with yourself:SURNAME FIRST NAME MALE OR

FEMALE

AGE DATE OF BIRTH

REGISTERED DISABLED

RELATIONSHIP TO YOU

DO THEY LIVE WITH YOU?

Applicant

Customer Services Centre Address:33-35 Chorley New Road, Bolton, BL1 4QR Telephone: 0800 970 6363 Fax: 01204 375768

Are you, or any of the people to be rehoused with you, expecting a baby? Yes NoIf yes, who is expecting and when is the baby due? ______________________________________(Please attach proof of pregnancy, ie, copy of certification or confinement.)Do you, or anyone moving with you:

Have difficulty climbing stairs

Use a wheelchair in the house

Need ground floor accommodation

Require special adaptations

If yes, please give details

WHERE DO YOU LIVE AT THE MOMENT?

Local Authority accommodation

Housing Association/Registered Social Landlord

Private Tenant

Owning or buying

Living with friends/family

Self-contained supported housing tenant

Hostel/shared supported housing

Approved probation/bail hostel

Children’s home/foster care

Hospital

Prison

Residential care home

Bed and breakfast

Squatting

Sheltered accommodation

No fixed abode

Other ____________________________

DETAILS OF YOUR PRESENT HOME

How many bedrooms does your present home have? _______DO YOU HAVE (TICK ONE BOX ONLY): YES NO SHARED IF SHARED, WHO WITH

Use of a bath or shower

An inside toilet

A separate bedroom

A separate kitchen

Central heating or storage heaters

A hot water supply

PROPERTY CONDITION

Does your home have any of the following: Leaking roof

Dangerous electrical wiring

Severe damp

Rain water penetrating property

Other, please describe _____________

WHO ELSE CURRENTLY LIVES WITH YOU WHO IS NOT MOVING WITH YOU?SURNAME FIRST NAME MALE OR

FEMALE

AGE DATE OF BIRTH

REGISTERED DISABLED

RELATIONSHIP TO YOU

DO THEY HAVE THEIR OWN ROOM?

WHY DO YOU WANT TO MOVE? To be rehoused from short-stay

hostel

To be rehoused from an institution

To move-on to supported self-contained housing

To receive higher support

I need specially adapted accommodation

I have been asked to leave home

To leaving home of family or friends by choice

I am a rough sleeper

To get away from racial harassment

To get away from other harassment

To get away from domestic violence

I have problems relating to physical health

I am a refugee/asylum seeker

To get help with alcohol/drug rehabilitation

I am on a probation service order

I have been evicted from my housing

Other ______________________________

HOW WOULD YOU DESCRIBE YOUR CURRENT ECONOMIC STATUS?

Working full-time

Working part-time

Training full-time

Training part-time

Voluntary Work

Foster Parent

Full-time carer

Unemployed

Retired

Student

Sick

Higher Education

Further Education

Job Seeker Allowance

Incapacity Benefit

Income Support

Disability/ DLA

Prefer not to say

Other (please state)______________

Home – not seeking work

Are you in receipt of any welfare benefits? If yes, which ones_________________________________________________________________If no, what is your weekly income? £__________________________________________________Do you have any debts or outstanding housing arrears? (Please give details) _________________If you must leave your present address, what date must you leave by? _____________________

DO YOU QUALIFY FOR ANY OF THE FOLLOWING?

Housing Benefit

Residential Allowance

Neither HB or Residential Allowance

Don’t know

If you are a tenant in your current property, please provide the Landlord’s name, address and telephone number:

________________________________________________________________________________________________________________________

_________________________________________________________________

If you are the owner, or part-owner of this property:How much is the property worth? £______________________________How much of your mortgage is left to pay? £______________________________Number of years left on your mortgage ____(Your building society or lender will tell you.)Is the property currently for sale? Yes No

Do you, or anyone to be rehoused with you, own any other properties? Yes NoHave you sold any properties within the last 5 years?If yes: Address of sold property ______________________________________________________Date of sale _________ Sale price £___________ Amount of equity/capital gained £ ______Do you, or anyone being rehoused with you, keep any pets? Yes NoIf yes, please say what type of pet you have and how many?______________________________Have you applied to the Salvation Army Housing Association in the past? Yes NoIf yes, when? ____________________________________________________________________Are you on a Council’s waiting list? Yes NoIf yes, which one? ________________________________________________________________Are you any other Housing Association’s waiting list? Yes NoIf yes, which one? ________________________________________________________________

REFERENCES

Please give details of your addresses over the last 10 years. If you have not held A TENANCY PREVIOUSLY, PLEASE GIVE DETAILS OF TWO PERSONS WHO COULD PROVIDE A PERSONAL CHARACTER REFERENCE.

Previous address From To Reason for leaving

You

Oth

ers

Name & Address of Referee Relationship to applicant

Date known since

ADDITIONAL INFORMATION ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

StatementPlease read this declaration and sign below. I understand that the Association will decide whether to allocate a tenancy/licence agreement based on the information on this form. The information I have given is true and complete to the

best of my knowledge. I will tell the Association if my circumstances change. The Association reserves the right to apply to the courts to take back any tenancy/licence agreement that is given based on false information.It is the Association’s policy to grant joint tenancies wherever applicable for general needs accommodation. All applicants who wish to be included on the tenancy/licence agreement and are over the age of 16 must sign below.

Signed _______________________________________________ Date _____________________

Signed _______________________________________________ Date _____________________

Information supplied on this form may be put on our computer and used as part of our allocations policy. We will treat the information you give us as confidential and will only use it to assess your housing needs. Before returning this form, please make sure ALL questions are answered fully. Please return the completed form to address on the front of the form.

EQUAL OPPORTUNITIES MONITORING FORM

The Association operates policies designed to ensure that all applicants receive equal treatment, regardless of their ethnic origin, sex or physical disability. To enable the Association to monitor whether its policy is fully carried out, will you please provide the following information. This information will NOT affect your application, and if you would prefer not to answer the questions, this view will be respected.

FIRST APPLICANT

How would you describe your ethnic origin?

White British

White Irish

White other

Mixed: white & black Caribbean

Mixed: white & black African

Mixed: white & Asian

Mixed: other

Asian/Asian British: Pakistani

Asian/Asian British: Bangladeshi

Asian/Asian British: other

Black/black British: Caribbean

Black/black British: African

Black/black British: other

Chinese

Asian/Asian British: Indian Other

Do you consider yourself to have a disability? Yes NoDo you use a wheelchair? Yes No

What is your religion?

Christianity

Hinduism

Islam

Judaism

Sikhism

Buddhism

No religious beliefs

Prefer not to say

Other (please state)__________________

Are you: Male Female

SECOND APPLICANT

How would you describe your ethnic origin?

White British

White Irish

White other

Mixed: white & black Caribbean

Mixed: white & black African

Mixed: white & Asian

Mixed: other

Asian/Asian British: Pakistani

Asian/Asian British: Bangladeshi

Asian/Asian British: other

Black/black British: Caribbean

Black/black British: African

Black/black British: other

Chinese

Asian/Asian British: Indian Other

Do you consider yourself to have a disability? Yes NoDo you use a wheelchair? Yes No

What is your religion?

Christianity

Hinduism

Islam

Judaism

Sikhism

Buddhism

No religious beliefs

Prefer not to say

Other (please state)__________________

Are you: Male Female