APPLICATION FORM FOR HOUSING
• Please fill in the form fully and clearly, with a pen• Please tick 4 correct boxes, complete all sections and sign and date the form on the back page.
• If you need help to fill in the form please ask us.
Please reply to :
St. Vincent’s Housing Association Limited 1st Floor Metropolitan House 20 Brindley Road Old Trafford Manchester M16 9HQ telephone 0161 772 2162 fax 0161 772 2121 minicom 18002 0161 772 2156 www.svha.co.uk
Registered Charitable Housing Association No. 19947R
1. Personal details
Please tick or fill in the relevant boxes
Applicant Joint Applicant
Title
Mr Ms Miss Mrs Mr Ms Miss Mrs
Gender (sex)
Male Female Male Female
Surname / Last Name First Name(s)
(including middle names if applicable)
Unmarried / Previous Name(s) Date of Birth Age National Insurance Number Present Address
(or c/o if applicable)
Post Code(s) Date moved into this address
Contact telephone number(s) Home Home
including area code(s) Work Work
Mobile Mobile Email address
Landlord Name Landlord Telephone Number Landlord Address
What relation is the joint applicant to yourself?
partner husband wife friend other (please specify)
March 2014
Application type: Direct Choice Based Letting Transfer Nomination
Printed on stock from sustainable sources
* Please also attach copies of all relevant documents confirming your status in the United Kingdom. This may include a copy of your passport, any relevant Home Office documentation or Work Permit.
ANY FORMS NOT COMPLETED FULLY WILL NOT BE PROCESSED
FOR OFFICE USE ONLYAPPLICATION NO: OFFER NO: DATE
4. Type of home you require Type of property you require.
Please tick all those which you require or would consider. Flat House: Terraced
House: Semi Detached House: Detached House: Mews Townhouse
Bungalow: Terraced Bungalow: Semi Bungalow: Mews Bungalow: Detached
Studio Flat Bedspace Garage Shared Flat
If you have indicated you want a flat which floor level would you consider?
Any Ground Floor 1st Floor 2nd Floor / Above
3. About your household
Male or Date of Relationship Is this person
First name(s) Surname Female Birth to you moving with you? Ethnicity
Yes No
Yes No
Yes No
Yes No
Yes No
Are you or any of these people expecting a baby? Yes No
If yes, who?
Date the baby is due (please enclose proof of pregnancy)
Do you have access or custody of children? (please enclose proof) Yes No
Also list anyone not currently living with you that will be moving into your new home
Full name Current address Reason for living apart
List the names of everyone who currently lives with you and indicate if they will be moving with you.
DO NOT INCLUDE DETAILS OF YOURSELF OR JOINT APPLICANT
2. Income Please give details of all income by ticking below:
Work full time (30 hours or more) Work part time (17 - 29 hours) Work part time (1 - 16 hours)
Wholly from Benefits Partly from Benefits Occupational Pension
State Pension
If working, what is you occupation? Length of employment?
Please give details of any income Main Joint Other Amount Per Per Per Per app app person £ week 2 week month 4 week Salary/wages
Job Seekers Allowance Contrib. Income based ESA
Contrib. Income based DLA - Mobility Element
Low Medium High DLA - Care Element
Low Medium High PIP payment
Incapacity Benefit Income Support Child Benefit Child Tax Credit Working Tax Credit Occupational Pension Pension Credit
Universal Credit State Pension
Do you have any savings? Yes No If Yes, how much? Do you have a bank account? Yes No
How many bedrooms do you require?
Are you or any of the people moving with you a wheelchair user? Yes No
Do you or any of the people moving with you require any adaptations? Yes No
If Yes, please attach written proof and tick all that are applicable.
Level Access Shower Low Access Shower Walk in shower
Shower over bath Grab Rails Ramp bath lift
Downstairs Toilet Low Toilet Wash & Dry Toilet
Where do you want to live?
Please refer to St Vincents Area Lists which have been sent out with this pack and tick all which are applicable. Please note that for Bolton, Manchester, Salford, Pendle, Hyndburn, Rossendale and Burnley you would need to register with the Local Choice Based Lettings scheme. Please see the information pack for details or contact us for further information.
North Manchester Harpurhey Moston Blackley
East Manchester Openshaw Gorton South Manchester
Whalley Range Northenden Wythenshawe Rusholme/Fallowfield
Bolton (All Of) Kearsley Farnworth/Moses Gate Great Lever
Westhoughton Horwich Hal’ithwood Bolton Central
Calderdale (All Of) Todmorden Hebden Bridge Mytholmroyd
Sowerby Bridge Bury Pavillion Court Radcliffe Court
Spring Street/East St Ribble Valley (All Of) Clitheroe Sabden
Whalley Clayton Le Dale East Lancashire (All Of) Nelson/ Brierfield Barnoldswick/Earby Accrington Oswaldthistle Great Harwood Rossendale Blackburn with Darwen Rochdale (All Of) Milkstone/Deeplish
Spotland Milnrow Shawclough Smallbridge
Sudden Newbold Middleton Heywood
Sparthbottom Castleton Wardle Norden
Trafford (All Of) Urmston Stretford Flixton
Altrincham Sale Salford (All Of) Eccles
Little Hulton Pendlebury Walkden Irlam
Cadishead Higher Broughton Central Salford St Helens (All Of)
Haydock Warrington (All Of) Tameside
Over 60’s Sheltered Schemes
Alexander Briant Court Alice Ingham Court Lisbon Street
Charles Forbes Court Dunstan Court Vaughan Avenue
Khubsuret House Margaret Ward Court Hurst Street
Mount Carmel Court (Extra Care) Plessington Court (partial Extra Care) Swithun Wells Court
Thomas Garnet Court Philip Howard Court Vincent Court
5. Why do you want to move?
The Information you give us will determine whether you are accepted onto the waiting list and which priority you will be given. (See information pack for more details. If necessary please tick more than one box.)
Overcrowded (lacking 1 Bedroom or more)
Homeless due to reasons other than applicants actions or ommissions (written proof required)
Threatened with homelessness due to reasons other than applicants actions or ommissions (written proof required)
Underoccupation
(moving from social rented property only. From family property to none family property)
Health problems / disability
(please attach written proof eg from doctor or Occupational Therapist)
Permanent decant
Home in poor condition (written proof required)
Relationship breakdown
Need independant accommodation Difficulties rent / mortgage
Eviction / repossession for other reasons other than applicants
From Prison / Hospital / Institute Daily support required or provided
(written proof from agency / social services)
To be near family / friends etc Required / asked to leave
Racial harrasment (written proof required from police or other agency)
6. Your present housing What is the Tenure of your current property?
Please tickWhat Type of property is it?
Flat House: Terraced House: Semi Detached
House: Detached House: Mews Townhouse
Bungalow: Terraced Bungalow: Semi Bungalow: Mews
Bungalow: Detached Studio Flat Bedspace
Shared Flat
How many bedrooms are in the property?
How many of the bedrooms are available to you?
If you are a tenant how much is your rent / boarding / lodging costs
(this is for information only and will not affect your application) £ week
Do you currently receive Housing Benefit? Yes No
Private Rented Property SVHA General Needs Other HA /
LA General Needs
Supported Accommodation Young Persons Supported Other Sheltered Accomm Family
Friends
University / Further Education Childrens Home /
Foster Care
Hostel /
Shared Accommodation Prison
Probation / Bail Hostel Hospital
Women’s Refuge Bed & Breakfast Direct Access Hostel Short Life Housing Tied Housing
Decant / Emergency Works Mobile Home / Caravan
Any Other Temp. Accomm Home Office Asylum Support
Rough Sleeping
Owner / Occupier Private Own / Occupy Low Cost Housing Other (please state)
Refugee (written proof of immigration status required)
Domestic abuse (written proof required eg letter from police or other agency)
Insecurity of tenure
Loss of tied accommodation (written proof required)
Harrasment / neighbour nuisance (written proof required)
Need YP Supported Housing
Threat of violence (written proof required eg letter from police or other agency)
Leaving armed forces
Living in temporary accommodation Need OP Supported Housing
Employment - to be closer to place of employment or offer of employment (written proof required)
Owner Occupier preference for rent Needs Supported Housing
Other please state
Please give any further information which you feel may help us assess your application.
If you own your own home will you be selling it? Yes No If yes, what is the approximate value?
7. Have you or a member of your household in your current or previous tenancy...
Been served with a Notice to Seek Possession,a Possession Order or been evicted? Yes No
Caused damage to any property? Yes No
Owe any housing debit, including rent arrears or recharges? Yes No
Committed Anti-Social Behaviour/Neighbour Nuisance or been the
subject of an injunction or Anti-Social Behaviour Order? Yes No
Convicted of a criminal offence?
(if ‘Yes’, this information may be checked with other agencies) Yes No
Ever used violence or threatening behaviour against a landlord,
their employees, agents or contractors? Yes No
Abandoned property? Yes No
Been asked to leave a property? Yes No
Have you had any failed tenancies not already mentioned? Yes No
If you have said ‘Yes‘ to any of the above, please give details:
8. Any support you may need
St Vincents is committed to helping people sustain their tenancies for the long term and can make referrals where necessary for support. Please answer the following questions to assist us with assessing any support needs.
Do you currently receive support to manage your current Tenancy
or received support in the last 2 years? Yes No
If yes please give details of what the support is for e.g. manage your health needs including mental health, problems due to anti social behaviour, young person leaving care, Tenancy support, community phsyciatric nurse etc.
Do you own a pet? Yes No If yes what is it?
Please give details of addresses over the last five years where you (and the joint applicant if applicable)
have lived, indicating whether Council or HousingAssociation Tenants. Start with your present address.
Applicant Address Date from Date to
If you are a private, council or housing association tenant or lodging please give name and address of your landlord
10. Emergency Contact
Please give name, address and telephone number of someone we can contact in case of an emergencyName Address
Telephone
9. Relationship to Staff or Board
Employees, Board Members or their close relatives have to seek special permission from our Board of Management if they want to apply for St. Vincent’s Housing, so if you or any member of your household is an employee, board member or one of their relatives, please give details.
11. Equal Opportunity in Housing
St Vincent’s Housing Association Ltd wants to ensure that all its customers are treated fairly and that no-one is discriminated against. We ask all our customers to complete this form so we can monitor the service we provide you, make sure we investigate any inequalities and remove any disadvantage to you accessing any service. The information you provide us will help us;
• Know who is using our service and if people are satisfied. • Ensure we remove any barriers identified for a particular group • Ensure our Equality and Diversity policy is working
• Make sure you receive service relevant to you for example if you ask for information in audio we can send you information in this format in the future.
This information is kept strictly confidential. You do not have to complete the form, but it will help us improve our services if you do.
If you already have support which will continue once you are a tenant with St Vincents Housing please provide details of the support provided and support providers details (Name, address and phone numbers)
Would you require support to manage your tenancy if you are
offered a tenancy with St Vincents Housing Association? Yes No If yes please specify what support and why e.g. first tenancy, cultural needs
learning difficulties, drug or alcohol dependency support.
PLEASE NOTE we will discuss with you prior to offering a tenancy what support you will need and make any necessary referrals.
Disability
Do you consider yourself disabled? (please tick relevant box)
Joint Joint
Tenant Tenant Tenant Tenant
Autism Deafness
Deaf-Blindness Mental Health
Hearing Impairment Learning Disability
Mutiple Disabilities Orthopedic Impairment
Other Disability/Health Impairment Speech or Language Impairment
Visual Impairment Mobility/Wheelchair User
Mobility/Non Wheelchair Blindness
Housebound None
Ethnicity
Do you consider your ethnic origin to be:
a. White British Irish Other
b. Mixed White and Black Caribbean White and Black African
White and Asian Other
c. Asian or Asian British Indian Pakistani
Bangladeshi Other
d. Black or Black British Caribbean African Other
e. Chinese or ethnic group Chinese Other
f. Any other Ethnic Group not listed, please specify g. Question refused
Please confirm your Nationality as it appears on your passport
Please also attach copies of all relevant documents confirming your status in the United Kingdom. This may include a copy of your passport, any relevant Home Office documentation or work permit.
Religion / Belief
What is your religion or belief?
No religion Christian Muslim Buddhist Hindu Jewish Sikh Prefer not to say Other religion, please specify
Sexual orientation
What is your sexual orientation?
Heterosexual Gay Lesbian Bisexual Prefer not to say
Format
If you are not a British National, please state which language would you prefer us to speak to you in. If you would prefer any documents in another format or language please specify for example in Braille, large print, audio or another language such as Urdu, Polish etc.
12. Statement
St Vincent’s Housing Association allocates accommodation according to housing need, so it is essential that the information you supply to us is accurate. By checking the box below both you and any joint applicants are stating that you agree to the following statements. You should read this carefully before you proceed.
1. I/we declare that the information given on this form is true to the best of my/our knowledge.
2. I/we understand that if St Vincent’s Housing Association offers to provide a tenancy on the basis of a false statement made by me/us or misleading information; or if I/we withhold information which I am/ we are supposed to declare then the application may be cancelled.
3. If I/we were granted a tenancy because I/we have given false or misleading information, or because I/we have not given information that I/we are supposed to give, or have failed to inform St Vincent’s Housing Association if my /our circumstances change, it is an offence and my/our tenancy may be terminated and I /we may have to pay a fine of up to £5000 under Section 171 of the Housing Act 1996).
4. I/we authorise St Vincent’s Housing Association to make whatever enquiries are necessary before they can confirm acceptance onto a waiting list or make an offer of a property.
5. I/we authorise any relevant agencies to disclose to St Vincent’s Housing Association whatever information is requested as part of this investigation.
6. I/we authorise St Vincent’s Housing Association to carry out a credit referencing check as necessary. 7. I/we must inform St Vincent’s immediately if any of my/our circumstances change.
I confirm that I have read and fully understand and accept the terms above. I confirm that any joint applicants have also read and fully understand and accept the terms and have authorised me to check the box on their behalf.
Confidentiality & Data Protection
Information provided on this application form will be held and used in accordance with the Data Protection Act 1998.
St Vincent’s Housing Association will only process data provided by the applicant and supplied to any third parties for the purposes of processing this application and to manage any subsequent tenancy. The information that is provided along with any necessary additional information supplied by third parties will be collated on computer and will be used as part of our banding process.
Information will be kept confidential and will only be disclosed to third parties on the basis that the information remains thus. The disclosure of such information will be strictly limited and will only be supplied for the purposes of dealing with this application or as required or permitted by law.
We advise applicants that data held by this organisation in respect of your housing application will be used for cross system and cross body comparison purposes for the prevention and detection of fraud.
I confirm that I have read and fully understand and accept the terms above. I confirm that any joint applicants have also read and fully understand and accept the terms and have authorised me to check the box on their behalf
Signed
(applicant) Date
Signed
(joint applicant) Date
In future, if you wish to check the information you have given on this form, please contact our office. You have the right to see the information. If your circumstances change, let us know.
Checklist
Before returning the form please ensure you have:
• Completed all parts • Signed and dated the statement • Enclosed all relevant information If parts are missing it may delay your application being processed.