Housing Options Application

HOUSING OPTIONS APPLICATION

Case Officer:
Application Number: / PLEASE COMPLETE & RETURN YOUR FORM TO:
Housing Options
Watling House
High Street North
Dunstable
Bedfordshire LU6 1LF
Details of Applicants
Title / First name / Surname / Gender
M/F / DOB / Nationality
1
2
Email Address / Phone contact details
Household Details
Title / First / Surname / Gender
M/F / DOB / Age / Relationship to applicant
Is any household member pregnant? please state:
Name Expected due date
Do you have any pets? (it may not be possible for your pet to be re-housed with you)
Yes / No
Current Address
Address (including postcode) / Occupation start date
Your right of occupation – Please tick box
1.Private Rent / 4 Rent from Housing Association
2 Sharing with family / friends / 5. Rent from Local Authority
3 Owner Occupier / 6. Temporary Accommodation
Other please specify –
If you rent accommodation please provide Landlord’s name, address & contact details:
Have you been asked to leave your home?
Yes / No
If yes, give details, (including dates of any notice served)
1st Applicant Address History– Addresses occupied over the last five years
(Use extra sheet if necessary)
Address / Date moved
in / Date moved out / Right of Occupation
(see table above) / If rented; Landlords name, email and phone no / Arrears
Y/N
2nd Applicant Address History– Addresses occupied over the last five years
(Use extra sheet if necessary)
Address / Date moved
in / Date moved out / Right of Occupation
(see table above) / If rented; Landlords name, email and phone no / Arrears
Y/N
Education – details of current schools attended
Child Name / School/college name and address
FINANCIAL DETAILS
Details of any rent or mortgage arrears
Amount / Payment plan? Amount each month? / Address & contact details of lender or landlord owed arrears
Income (Earnings and Maintenance)
Name of Applicant / Name, address of employer or other source of income / Net monthly income
Income Benefits (include any Housing Benefit)
Name of Applicant / Benefit Claimed / Average Monthly figure
(weekly x 52/12)
Income – Money owed to you
Are you expecting any financial settlement?
Yes / No
If yes, give details;
Outgoings - do you have any County Court Judgements?
Yes / No
If yes, give details, (including details of payment plans)
Outgoings – Do you pay maintenance to dependants not being housed with you?
Yes / No
If yes, give details
SUPPORT & WELLBEING
Does any member of your household :-
consider themselves to be disabled? / Yes No
registered disabled? / Yes No
have a medical condition which requires specialist or ground floor accommodation? / Yes No
use a wheelchair? / Yes No
have difficulty walking or climbing stairs? / Yes No
have hearing or sight impairment? / Yes No
have a learning difficulty? / Yes No
need housing with staff support? / Yes No
receive support from Social Services, Health Visitors or some other support service? / Yes No
Please provide details of any support received by any member of your household
Support Worker Name / Organisation / Address / Tel No
Who receives the support? What type of support service is provided and how often?
Medical Conditions
Please provide details of any medical conditions and any medication. Who has this condition and how does this affect their daily living in the current home?
Caring Responsibilities
If you provide care for anyone please provide name and address of person you care for;type of care you provide and how often.
Previous Residence in the Armed Forces; Institution (Prison) or Care
Please give details if you have:
served in the Armed Forces;
have been in Local Authority care;
have served a prison sentence (including youth detention)
REHOUSING
Areas where you would prefer to be rehoused?
Areas you consider are unsuitable and why?
Do you have your own transport?
To establish your local connection, please provide details of an adult family member who has lived in the Central Bedfordshire area over 5 years. (Family includes Mother/Father/Brother/Sister)
Relationship / Name / Address / How long occupied

In order to help us achieve our equal opportunities policy it would be of great help to us if you tick the appropriate boxes. However, it is not obligatory to complete this section and it will not affect your chances of being housed if you do not do so.

How would you describe your origins?(tick below)
White British
White Irish
White other
Mixed – white and black Caribbean
Mixed – white and black African
Mixed – white and Asian
Mixed other
Indian
Pakistani
Bangladeshi
Asian other
Black Caribbean
Black African
Black other
Chinese
Other ethnic group
Question refused
When returning this form you MUST enclose COPIES of the following:
(tick below)
Proof of income
If in receipt of benefits a COPY of your latest assessment letters or bank statements to show benefits.
If in paid employment, COPIES of your most recent payslips -2 if paid monthly
-4 if paid weekly
If in receipt of Child Benefit, a COPY of proof of entitlement.
Confirmation of pregnancy – if applicable.
COPIES of any letters or documents that you feel may support your application.
Any notice to quit letter
Completed Income and Expenditure form
Copy of passport/driving licence/birth cert for each adult applicant
Supporting Medical information and / or details of any care packages received
Please state
Sexual Orientation
Religion

CURRENT INCOME & EXPENDITURE

EXPENDITURE / £ / PLEASE CIRCLE
M – MONTHLY
W-WEEKLY
RENT
GROUND RENT & SERVICE CHARGES
MORTGAGE
OTHER SECURED LOANS
MORTGAGE ENDOWMENT AND MPPI
BUILDING AND CONTENTS INSURANCE
PENSION AND LIFE INSURANCE
COUNCIL TAX
GAS
ELECTRICITY
WATER
OTHER UTILITIES (COAL, OIL, CALOR GAS)
TV LICENCE
MAGISTRATES COURT FINES
MAINTENANCE OR CHILD SUPPORT
HIRE PURCHASE/CONDITIONAL SALE
CHILD CARE COSTS
ADULT CARE COSTS
HOME PHONE
MOBILE PHONE
PUBLIC TRANSPORT (EG. WORK/SCHOOL/SHOPPING)
OTHER (EG. TAXIS)
CAR INSURANCE
ROAD TAX
FUEL (PETROL/DIESEL, OIL ETC)
MOT AND CAR MAINTENANCE
BREAKDOWN OR RECOVERY
PARKING CHARGES OR TOLLS
OTHER CAR COSTS
FOOD & MILK
CLEANING & TOILETRIES
NEWSPAPERS & MAGAZINES
CIGARETTES & TOBACCO
ALCOHOL
LAUNDRY AND DRY CLEANING
CLOTHING AND FOOTWEAR
NAPPIES AND BABY ITEMS
PET FOOD
REPAIRS/HOUSE MAINTENANCE (INC.WINDOW CLEANING, MAINTENANCE CONTRACTS)
HAIRDRESSING/HAIRCUTS
CABLE, SATELLITE AND INTERNET
TV, VIDEO AND OTHER APPLICANCE RENTAL
SCHOOL MEALS / MEALS AT WORK
POCKET MONEY / SCHOOL TRIPS
LOTTERY AND POOLS ETC.
HOBBIES/LEISURE/SPORT (INC. PUB/OUTINGS, GYM ETC)
GIFTS (CHRISTMAS, BIRTHDAYS, CHARITY ETC)
VET BILLS AND PET INSURANCE
HEALTH (EG. PRESCRIPTIONS/DENTIST/GLASSES ETC)
OTHER (EG POSTAGE)
TOTAL EXPENDITURE / £
ASSETS OR EQUITY / £
TOTAL VALUE OF PROPERTY(IES)
MORTGAGE OUTSTANDING
SECURED LOAN(S) OUTSTANDING
VALUE OF VEHICLE(S) LESS HP OUTSTANDING
SAVINGS
OTHER ASSETS
£
INCOME
CLIENTS SALARY/WAGES (TAKE HOME)
PARTNERS SALARY/WAGES (TAKE HOME)
MAINTENANCE OR CHILD SUPPORT
BOARDERS OR LODGERS
NON-DEPENDANT CONTRIBUTIONS
STUDENT LOANS AND GRANTS
JOBSEEKERS ALLOWANCE (INCOME BASED)
JOBSEEKERS ALLOWANCE (CONTRIBUTION BASED)
INCOME SUPPORT
UNIVERSAL CREDIT
HOUSING BENEFIT
WORKING TAX CREDIT
CHILD TAX CREDIT
CHILD BENEFIT
INCAPACITY BENEFIT/STATUTORY SICK PAY
DISABILITY LIVING ALLOWANCE / ATTENDANCE ALLOWANCE
CARER’S ALLOWANCE
OTHER (EG. MATERNITY ALLOWANCE/SMP ETC)
STATE PENSION(S)
PRIVATE OR WORK PENSION(S)
PENSION CREDIT – GUARANTEE SAVINGS
OTHER
TOTAL INCOME / £
PRIORITY DEBTS / AMOUNT OWED (£) / CURRENT REPAYMENTS
RENT
MORTGAGE
OTHER SECURED LOANS
MAGISTRATES COURT FINES
COUNCIL TAX
MAINTENANCE OR CHILD SUPPORT
GAS
ELECTRICITY
WATER
CCJ
HIRE PURCHASE OR CONDITIONAL SALE
OVERPAID BENEFITS
TOTAL PRIORITY DEBTS / £
NON-PRIORITY DEBTS / AMOUNT OWED (£)
TOTAL NON PRIORITY DEBTS / £
DECLARATION
I declare that this application has been completed by me/us and that the information I/we have given is correct and complete
Signature: / Name / National Ins. No. / Date
Signature: / Name / National Ins. No. / Date
OFFICE USE ONLY
Check List
Original passport seen? / Yes/No
Copy of Passport supplied? / Yes/No
All documents supplied? See checklist / Yes/No
Eligible (recourse to public funds) ? / Yes/No
Care package attached? / Yes/No
Risk assessment - risks identified? / Yes/No
Medical evidence? / Yes/No
Referral made to gateway? / Yes/No
Experian Check and report attached? / Yes/No
Any CCJ’s or debt? / Yes/No
Referral to Pay Plan or Step change? / Yes/No
Copies of repayment plan attached? / Yes/No
Police check carried out & attached? / Yes/No
Housing Benefit check carried out? / Yes/No
Any HB overpayments? / Yes/No
Landlord confirms reason for homeless? / Yes/No
Any breach of tenancy? / Yes/No
Private Let Discharge only? / Yes/No
Is application to be treated as an application for Kilgour Court? / Yes check boxor leave blank
Case Officer / Name / Date
Senior Officer / Name / Date

DECLARATION AND CONSENT

I/we have asked Central Bedfordshire Council to assist and advise me/us to obtain or retain housing accommodation. I/we understand that legal action may be taken against me/us if I/we obtain accommodation as a result of giving false or misleading information. I/we understand that the Council may check and verify any information I/we provide. I/we understand that I/we must inform the Council of any changes affecting my/our application as soon as they occur. I/we declare that the information given is correct and complete.

I/we authorise the Council to contact other organisations, including the Police, on my/our behalf to obtain any other information in support of my application for assistance; for information to be shared with other agencies, agents and departments of the Council and for 3rd parties to release information to the Council, that can support me/us with any issues relating to my application.

RELATIONSHIP TO COUNCILLORS, EMPLOYEES, HOUSING ASSOCIATIONS

Is anyone named in this application: -

a member of, or employee of, the Council / Yes/No
related to a member of, or an employee of, the Council / Yes/No
an employee of or related to an employee of a Housing Association with which Central Bedfordshire Council has nomination rights / Yes/No

If YES, give details ………………………………………………………………………………………

USE OF YOUR INFORMATION

All personal information held by the Council is subject to the Data Protection Act 1998

The Council must protect the public funds it handles, and so may use the information you have provided on this form to prevent and detect fraud. This may include a Credit Check to verify that your details are correct. Your information may also be shared with other organisations that handle public funds.

Sections 171 and 214 of the Housing Act 1996 make it an offence for anyone to knowingly give false information or to withhold information in relation to their housing or homelessness application.

Ground 5, Schedule 2 of the Housing Act 1985 (as amended by section 146 of the Housing Act 1996) enables action to be taken to seek possession of any tenancy which has been granted as a result of a false statement by the person or person acting at the tenant's instigation.

I/We have read and fully understand the statements above and authorise the Council to verify the information I/We have provided.

Signature: / Name / Date
Signature: / Name / Date

1

Housing Options Application 22 June 2017