Homelessness Assistance Application Form

Homelessness Assistance Application Form

1. Your Details

Title / First name / Surname / Gender / Tick / D.O.B / NI Number / Sexual orientation / Tick
Male / Heterosexual / Straight
Female / Gay / Lesbian
Transgender / Prefer not to say
Other / Other
Nationality(please choose only one) / Tick / Ethnicity (please choose only one) / Tick
UK national living in the UK / White: English/Welsh/Scottish/Northern Irish/British
UK national returning from living overseas / White: Irish
UK national in the UK for first time / White: Gypsy or Irish Traveller
Czech Republic / Any other White background
Estonia / Mixed ethnic groups: White and Black Caribbean
Hungary / Mixed ethnic groups: White and Black African
Latvia / Mixed ethnic groups: White and Asian
Lithuania / Any other mixed ethnic background
Poland / Asian/Asian British: Indian
Slovakia / Asian/Asian British: Pakistani
Slovenia / Asian/Asian British: Bangladeshi
Bulgaria / Asian/Asian British: Chinese
Romania / Any other Asian background
Croatia / Black/ African/Caribbean/Black British: African
Ireland / Black/ African/Caribbean/Black British: Caribbean
Other EEA country national / Any other Black/African/Caribbean background
Non-EEA country national / Other ethnic group: Arab
Nationality if not listed above: / Any other ethnic group
Prefer not to say
Immigration Status / Tick / Tick
British or Irish citizen, living in the UK, Ireland, Channel Islands, or Isle of Man, or deported from another country
EEA citizen: worker / Non-UK/EEA: Granted refugee status
EEA citizen: self-employed / Non-UK/EEA: Exceptional Leave to Remain
EEA citizen: permanent right to reside / Non-UK/EEA: Indefinite Leave to Remain
EEA citizen: other / Non-UK/EEA: Limited Leave to Remain
EEA citizen: A family member of one of the above groups / Non-UK/EEA: Other protection (e.g. humanitarian, discretionary)

Contact Information

Email / Phone Number / Other Contact Number / Spoken Language
Did you approachanother Local Authority or support agency/charity before contacting Newham Homelessness Prevention and Advice Service? / Yes 
No  / If yes, name of Local Authority/Support agency/Charity:
Worker’s name:
Contact details:

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1. Current Address information

What is your current housing situation, please tick?
Owner-occupier / Social rented supported housing or hostel
Shared ownership / Refuge
Privately renting a flat or house / Rough sleeping
Privately renting a room in a shared flat/house / Homeless leaving custody/prison
Living with my landlord in their home / Homeless leaving psychiatric hospital
Council tenant / Homeless leavinghospital
Housing Association/Registered Provider tenant / Council temporary accommodation
Armed Forces accommodation / Student accommodation
Tied accommodation e.g. provided through work / NASS accommodation
Looked after children placement / No fixed abode/sleeping in different places
Living with family / Caravan / houseboat
Living with friends / Other
Current address / Contact address
(if different)
Resident since / Expected leave date
Property type (Room, Flat, House, other please state) / Number of bedrooms
Rent paid (weekly/monthly) / Amount of deposit paid
Evictor/landlord name and relationship / Evictor/landlord contact number
Reason for needing to leave this address

2.1Other members you want to be included as part of your household

In the ‘relationship to you’ box please indicate if they are your; spouse, partner, parent, guardian, son, daughter, other relative, carer, lodger, tenant or other

Title / Forename / Surname / M/F / D.O.B / Age / NI Number / Relationship to you / Living with you now?
Does the household have a support pet e.g. guide dog or any other household pet? / Yes 
No  / Details if yes:

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1. Address History for you for the last 5 years

Dates / Address / Did you rent, own or stay with someone at this address / Reason for leaving / Contact details for the owner of the property

3.1Address History for your partner if different from above for the last 5 years (if not relevant go to question 4)

Dates / Address / Did they rent, own or stay with someone at this address / Reason for leaving / Contact details for the owner of the property

4.Children who do not live with both parents (If not relevant go to question 5)

Child’s name
Other parent’s name
Their contact number
Their address
Do you have contact with them
Does your childhave contact with them
How often is this contact
How long has this arrangement been in place
Can your child live with their other parent
Any other relevant information

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1. Your and your household circumstances

Is anyone in the household… / Y/N / Household member(s) / Details:
Pregnant / Due Date:
In education or childcare
Please provide:

• Name and address of school or provider
• Travel arrangements
• Length of travel time
• Start and finish times
• Days attended if not fulltime

If in exam years what subjects are being studied

• Any special educational support received

If you have more than 4 children in education or childcare, please add their details in section 8 ‘other information’ at the end of this application form. / Child’s name: / See notes on left:
Child’s name: / See notes on left:
Child’s name: / See notes on left:
Child’s name: / See notes on left:
Ever been in Social Services Care / Dates:
Ever served in HM forces / Dates:
Ever been on remand or served a custodial sentence / Dates:
Registered disabled or sight impaired / Details:
At risk of self harm or suffering a drug/alcohol addiction / Details:
At risk of domestic violence or abuse, gang related crime or a threat of violence or harassment of any type / Details, include any area(s) that maybe unsafe:

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1. Household Support Network (if not relevant please go to question 7)

Professional / Household member / Name of professional / Address and Contact Number / Type of support received
Social Worker
Probation Officer
Community Psychiatric Nurse
Carer(s)
Any unregistered childcare support e.g. family or friends
Other please specify

1. Disabilities and long term medical conditions (if not relevant go to question 8)

Household member / Name of diagnosed illness or disability and how it impacts your day to day life / Medication taken, including dosage, how often you take the medication and date medication started / Any special requirements relating to the type of accommodation or location you can live in e.g. if you need adaptations in your home or need to be close to a specialist treatment centre

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7.1Please give details of all professionals (e.g. GP, therapist, consultant,specialist) currently involved in your care for the medical conditions mentioned above and who you have seen in the last year

Household member / Name of professional / Contact details / Date last seen / Next planned visit

7.2Please provide details of anyhospital admissionsor operations within the last 12 months or which are planned within the next 12 months

Household member / Reason for admission/operation / Date took place/Expected date

1. Income, Savings, Assets and Expenditure

8.1 Paid work

Please tick which of these best describes your current employment status
Working: 30 hours a week or more / Not registered unemployed but seeking work
Working: less than 30 hours a week / Not seeking work as looking after the family
Training Scheme / apprenticeship / Retired (including retired early)
Full-time student / Not working due to long term sickness or disability
Registered unemployed and seeking work / Other
Please complete the table below for yourself if relevant and all other household members you want to live with you who are in employment
Household Member / Name of employer & location of work / Permanent/ Temporary / Hours per week / Job role / Earnings (weekly/monthly)

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8.2Benefits your household receives

Please tick all that you receive or that have been applied for
Name of Benefit / Tick / Amount received / Frequency(week/month) / Name of claimant
No benefits received in household
Housing Benefit / £
Council Tax Support / £
Discretionary Housing Payment / £
Universal Credit / £
Tax Credits (WTC, CTC) / £
Income Support / Carer’s Allowance / £
Jobseeker’s Allowance / £
Employment and Support Allowance / £
Disability Benefits (PIP, DLA, AA, IB, IIDB) / £
State Pension and/or Pension Credit / £
Bereavement Benefits (BP, WPA, BA, BSP) / £
Other please state: / £

8.3Other income, savings or assets

Household member / Other Income / Savings / Property owned, including property abroad
Details / Amount / Details / Amount
£ / £
£ / £
£ / £
£ / £
£ / £
£ / £
£ / £
£ / £

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8.4Expenditure

Please complete your current financial commitments – leave blank if not relevant
Amount Paid / Frequency (Weekly/Monthly) / Arrears amount
Rent/Mortgage / £ / £
Second Mortgage / Secured Loan / £ / £
Mortgage Endowment / £ / £
Ground Rent/Service Charge / £ / £
Council Tax / £ / £
Buildings/Contents Insurance / £ / £
Life Insurance / £ / £
Gas / £ / £
Electricity / £ / £
Water Rates/sewerage / £ / £
TV Licence / £ / £
Satellite/ Broadband/Landline / £ / £
Mobile Phone / £ / £
Food & Household items / £ / £
School Meals/Meals at Work / £ / £
Childcare Costs / £ / £
Maintenance/Child Support / £ / £
Travel Expenses / £ / £
Clothing / £ / £
Car running costs (repayments, insurance, fuel, etc.) / £ / £
Magistrates Court Fines / £ / £
Income Tax / £ / £
Credit Cards/Catalogues/unsecuredloans / £ / £
Other please state / £ / £

1. Other information

Please use this space to provide any addition information relating to your application, include who the information relates to and any dates if relevant. You may also want to include actions you have already taken to try and resolve you situation and any support you are seeking from the Council:

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1. Declaration and consent to sharing information

DECLARATION
It is a criminal offence and a breach of the provisions of S214 of the Housing Act 1996, Part VII (as amended) for anyone to try to obtain accommodation from a local authority by knowingly or recklessly giving false statement or knowingly withholding information.
Failure to notify the Council of any changes in your circumstances during the time your application is being processed and up to the time a decision is reached is also against the law.
The Council will take action where there is evidence of someone making a false application, has provided false information, withheld information or failed to notify us of changes in their circumstances, because it stops us from being able to help those who qualify for and need assistance. If found guilty of any offences under these provisions, you may be ordered to pay a fine of up to £5,000. Also the Council may seek possession of any tenancy that was granted as a result of a false statement.
The information you provide will only be used in connection with your application for housing assistance, providing you with necessary services, prevention of fraud (see next paragraph) and for statistical purposes, reaserch and verification. Your personal information will be shared with other Council Services for the same purposes only. All information will be treated as confidential and will be held and processed in accordance with the Data Protection Law. The Data Controller is the London Borough of Newham and the nominated Data Protection Officer is on the Council’s website at .
The Council is under a duty to protect the public funds it administers, and to this end may use the information on this form within this Authority for the prevention and detection of fraud. It may also share this information with other bodies administering public fundsand for the prevention and detection of crime.
In submitting this application you are giving your consent for us to act on your behalf and where appropriate to make contact with your excluder (landlord, friend, family member or any other agency that is asking you to leave) in an attempt to negotiate for you to remain or return to your home. We will discuss this with you before we make contact with them.
You are also consenting for the Homelessness Prevention and Advice Service to undertake any necessary checks to validate information you have supplied with the purposes of assisting you with your housing situation.
I HAVE CHECKED THE ABOVE SECTIONS, READ AND UNDERSTOOD THE ABOVE STATEMENTS
APPLICANT NAME / SIGNATURE / Date
PARTNER NAME / SIGNATURE / Date
address
For office use only
Northgate Number:

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