Marlborough & District Housing Association Ltd

Accommodation Application Form

Marlborough & District HA aims to provide accommodation for persons in need, over the age of 55, who are able to look after themselves.

Please indicate which type of accommodation you are interested in: /

FLAT BEDSIT

Date when accommodation may be required:
APPLICANT’S NAME
(print in capitals please) / Surname:……………………………….
Forenames:…………………………….
Full names of spouse (if applicable):
APPLICANT’S CURRENT ADDRESS / Telephone:
Please tick as relevant: / Single / Married /
Widowed
/ Divorced / Separated
Applicant (s) Date of Birth: / Applicant: / Spouse:
DETAILS OF PRESENT ACCOMMODATION
House / Flat / Bungalow / Lodging (delete as applicable)
Do you own the accommodation? (delete as applicable) / YES NO
Number of rooms you occupy
How long have you lived there? / …….. years / monthsdelete as applicable)
How much rent do you pay per annum? / £
Please let us know why you are leaving / wish to leave this accommodation(delete as applicable) / No longer suitable
To be close to relative
Homeless
Other (please state): …………………….
……………………………………………….
Do you have other accommodation?(delete as applicable) / Yes/No
If yes,
What is the rent? ……………………
What is the council tax?……………..
Have you previously owned a property (freehold or leasehold)? (delete as applicable) /
YES NO
Ifyes, please provide details on a separate sheet.

Name & address of 2 next of kin or persons with whom to communicate in case of need

1.
Telephone:
Relationship: / 2.
Telephone:
Relationship:
Would they assist you in case of illness? /

Yes No(delete as applicable)

Do you have any children: /

Yes No(delete as applicable)

Please give their address(es) and telephone number if different from information given as ‘next of kin’
(as above):
May we consult your doctor about your state of health? /

Yes No(delete as applicable)

Name, address, and telephone number
of your doctor: / Telephone:
How long have you lived in the Marlborough & District area?
Or, explain your connection with this area.
Do you own a motor car?
(Only one car per residence is permitted) /

Yes No (delete as applicable)

FINANCIAL INFORMATION

Please complete this section fully (for applicant & spouse), giving all relevant amounts in figures, entering ‘Nil’ where necessary

Income: Paid Work: / £ (per week)
State Pension: / £ (per week)
Social Security Benefits / £ (per week)
Occupational Pension / £ (per week)
Other benefits / £ (per week)
Capital: Amount of Savings: £
Net value of propert6y after mortgage/ loans are repaid: / £
Investments Savings / £ (per week)
Interest on savings / £ (yearly)
Income from any other sources / Please specify on aseparate sheet
It is essential that our residents are able to care for themselves, with the assistance of family and social services as necessary, as appropriate.
Please arrange for another person (not a relative) to sign below that the accommodation for which you are applying will meet your needs.
This should be a person who has known you for more than two years including your current or most recent landlord if applicable:
Full Name: …………………………………………………… Signature:…………………………………….
Address: …………………………………………………………………………………………………………….
.
…………………………………………………………………………………………………………………………
Telephone Number: ………………………… Connection to Applicant: ……………………………………

Please read the following, and sign & date the Agreement:

I / we, the applicant(s),
  • Agree to provide a medical certificate as to my/our state of health (if required).
  • Understand that there is no warden service provided.
  • Accept that, in the event of illness or other condition that makes it difficult for me to look after myself, it is for me to make arrangements for an appropriate care package to be provided by the Social Services or privately.
  • Understand that itis MDHA policy to help residents remain in their homes for as long as possibleprovided this is not adversely affectingthe other residents, but accept that there may come a time when the level of care that can be provided in my home is inadequate for my needs and that I may have to move into a Care Home.

I / we declare that the foregoing statements are true.
Applicant’s Signature(s): / …………………………………… / ……………………………………
Date: …………………… / Date: ……………………
Please return this form to the Secretary:
Mrs. A. Deuchar, Harlaw, Clatford, Marlborough SN8 4EB
Contact telephone number: 07887 924539

Applicants will be notified by the Secretary when suitable accommodation becomes available.

Please notify the Secretary if/when there are any changes in your circumstances.

Data Protection Statement
We will treat the information you provide for this application in accordance with the Data Protection Act 1998. Some details may be checked with relevant organizations but none will be disclosed for any other purpose. The data will not be passed on. You may have access to your personal information on request.

Page 1

Registered Office: 126 High Street, Marlborough, Wiltshire. SN8 1LZ. Housing Corporation Registration No. L1031.

Registered under the Industrial & Provident Societies Act 1965 (No.1760R)