Housing Application Form

Housing Application Form
This is an application form for private rental accommodation

CARE Housing aims to assist local people who are experiencing severe housing difficulties who are usually homeless, or under threat of homelessness, to find private rented accommodation with Landlords who have been approved by CARE Housing. WE CAN ONLY CONSIDER HELPING THOSE WHO FIT OUR CRITERIA below.

TERMS OF USE

1)    Homeless or under threat of homelessness

2)    Applicants must satisfy CARE Housing that they will engage with our services to sustain independent living and maintain their financial obligations to their landlords.

3)    Be in receipt of state benefits or on a low income and therefore without the means to pay a deposit and rent in advance.

4)    Be over the age of 18 with or without dependents. However, please note single people under the age of 35, with no dependents, will be considered on a case by case basis due to Housing benefit allowances. Single people over the age of 35 may be considered for a one bedroomed property.

5)    From the local community i.e.

· Have lived here for at least 6 months in the last twelve, or two out of the last five years.

·         Born in the area

·         Having strong local connections

·         Having good reasons to live in the area

E.g. A secured local job requiring relocation or domestic violence.

We will require evidence of your circumstances

We do not generally accept applications from tenants of any social landlord e.g. Shoreline or L & H Homes who wish to move to another/better area. You should approach your housing provider to discuss your move in the first instance. In the certain circumstance of genuine need, where it would prevent homelessness, we will consider social landlords tenants on a case by case basis.
Applicant

If you are applying to be a joint tenant with someone else you should include their details in the joint applicant column throughout this form.
Title

MrMrsMissMs
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
National Insurance Number
Relationship to Joint Applicant
Address*

Street Address

Street Address Line 2

Town/CityCounty

Post Code
On what date did you move into this address?
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Mobile Phone Number*
Please enter a valid phone number.
Email
example@example.com
If you have been previously known by another name please state it here
What language do you prefer to speak, read and write in?
What is your nationality?
Joint Applicant
Title

MrMrsMissMs
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
National Insurance Number
Relationship to Joint Applicant
Address

Street Address

Street Address Line 2

Town/CityCounty

Post Code
On what date did you move into this address?
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
If you have been previously known by another name please state it here
What language do you prefer to speak, read and write in?
What is your nationality?
What are your current circumstance and why do you require our help?*
Have you previously been homeless?

YesNo
Did a person or agency suggest that you come to us, if they did who was it? *
Will any pets be re-housed with you

YesNo
Please tell us how many and what kind?

Please tell us if you (or your partner/children) receive any benefits*

	Who recieves the benefit	Type of benefit	Amount (£)	Weekly / Monthly
1
2
3
4
5

If you or your partner are employed, please supply the following details:

	Name	Occupation	Name & address of employer	Length of Employment	Permenent or Temporary	Hours per week worked	Hourly Rate	Net/Take home salary
1
2

We need to know who will be living with you permanently in your new home. Please seek consent with the members of your household before sharing this information with us

	First Name	Surname	Sex	Date of Birth	Relationship to you	Receive Child Benefit
1
2
3
4
5
6

If you have indicated that any of the people named in this section do not currently live with you at present, please give details below.

	First Name	Surname	Sex	Date of Birth	Relationship to you	Receive Child Benefit
1
2
3
4
5
6

If anyone named in section 1 or 2 is an expectant mother, please give details below:

Name Date baby is due

1

	Name	Date baby is due
1

Applicant Please provide details of where you have lived in the last five years *

	Address	Date From	Date To	Weekly Rent	Reason for leaving	Name and address of landlord if renting
1
2
3
4
5
6

Joint Applicant Please provide details of where you have lived in the last five years

	Address	Date From	Date To	Weekly Rent	Reason for leaving	Name and address of landlord if renting
1
2
3
4
5
6

Has any legal action been taken against you, your partner or any person who intends to live with you for anti-social behaviour such as harassment or nuisance or have you previously been evicted for any reason?

YesNo
If yes, please give details, including property address, landlord details and reasons:
Do you or your partner, or any person who intends to live with you have a criminal record?

YesNo
If yes, please give details

If you or anyone who wants to be rehoused with you has any criminal convictions which are not spent as explained in the Rehabilitation of Offenders Act 1974, you must tell us about them here. You must set out all of the details of the conviction in full.

See the guidance notes about when a criminal conviction is spent

! Declaring Criminal Offences will not necessarily prejudice your application.

HOWEVER, FAILING TO DISCLOSE MAY RESULT IN AN AUTOMATIC DECLINE.

NEXT OF KIN

	Applicant	Joint Applicant
Name
Relationship
Contact Number
Address

Please indicate which applies to you:

	Applicant	Joint Applicant
Council tenant
Housing Association tenant
Private tenant
In tied accommodation
Staying with parents/relatives/friends
Lodging
Owner Occupier
In Armed Forces accommodation
A young person leaving Local Authority care
In prison
In hospital
In temporary accommodation

Please give us details of any Social Worker, Carer or other professional person who supports you.

	Name	Section & Address	Telephone Number
1
2

Please give us details of a person whom we can obtain a Character reference from

	Applicant	Joint Applicant
Character Reference Name
Profession/Occupation
Address
Contact Number

	Have you been given written notice to leave?	If yes when do you need to leave?	Why have you been asked to leave?
Applicant
Joint Applicant

What type of property would you prefer to move to

HouseFlat
How many bedrooms do you need?
Which floor level of accommodation do you need?

GroundFirst
Do you require any of the following?

AdaptionsA property suitable for wheelchair accessWhat adaptions or other facilities do you need?

In order to give us some idea of which areas of support that you currently think we might be able to help you with, please indicate in any of the boxes below:

	Applicant	Joint Applicant
1. Preventing Homelessness
2. Increasing Confidence
3. Improved health and wellbeing
4. Improving Life Skills
5. Access to basic Needs
6. Maximising Income

Please ensure that this information is enclosed with your completed application form.   If anything is missing we will not be able to process your application and will return it to you.

If we do not see the original documents when you return your form, we must see them if and when you are offered a tenancy.

Please tick to indicate what evidence you are providing (ü):

All Applicants and Joint Applicants:-
Proof of your identity

Any one of: Your passport, immigration documents, birth certificate, marriage certificate, driving licence, OAP travel pass, benefit book, NHS medical card

Proof of your current address

Any one of these showing your present address (unless NFA)

A utility or council tax bill, bank statement, insurance certificate, tenancy agreement, wage slip

If you have dependent children:-

Proof of any child benefit you receive

Your benefit book or Child Tax Credit Statements

If someone in your household is pregnant:-

Proof of pregnancy, stating the expected date of birth

Your medical certification provided by your doctor, midwife or hospital

If you have been asked to leave your current accommodation:-

Your written notice to quit

If you are able to provide any further evidence to support your application

Proof of your employment

Your wage slip or contract of employment
Please upload your supporting evidence documents

Cancelof
Applicant Signature*

Clear
Joint Applicant Signature

Clear
Equal Opportunities Monitoring Form

We keep records of people who apply to us for support. This is to ensure that our service is provided on an equal basis without discrimination on the grounds of age, gender, race, ethnicity, sexuality, disability or religion. Any information you choose to give us will be treated in confidence and will be used for monitoring purposes only.

We keep records of people who apply to us for support. This is to ensure that our service is provided on an equal basis without discrimination on the grounds of age, gender, race, ethnicity, sexuality, disability or religion. Any information you choose to give us will be treated in confidence and will be used for monitoring purposes only.
Gender

MaleFemaleOther
Age

Under 1818-2425-2930-3435-3940-4950-5960-6970+
Race

WhiteBlackAsianMixedOther
Ethnicity

BritishIrishAny other White backgroundAfricanCaribbeanAny other Black backgroundBangladeshiIndianPakistaniArabChineseAny other Asian backgroundWhite & AsianWhite & Black AfricanWhite & Black CaribbeanAny other Mixed backgroundGypsyRomanyTravellerPrefer not to say
Sexual Orientation

BisexualGayHeterosexualLesbianPrefer not to say
Disability (if yes please tick relevant box)

YesNoDon't knowMobilityVisual ImpairmentHearing ImpairmentMental health conditionAutistic Spectrum ConditionLearning DisabilityProgressive Disability/Chronic illnessOther
Religion

BuddhistHinduSikhMuslimJewishChristianPrefer not to sayNot knownNoneOther
Marital Status

SingleMarriedSeparatedDivorcedLiving with partnerOther
Marketing Permissions

Email
Marketing Permissions

Email
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