Liverpool Gingerbread Housing Co-operative Ltd

Housing Application

About you and your household

Surname / First Name / Date of Birth / National Insurance number of adults who are going to be re-housed with you / Relation
to you / Sex (male or female) / Is this person living with you now? / Is this person to be re-housed with you?
/ / / / / / / /
You
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
Current address and postcode
Phone Number
/ Home: / Work:
Mobile Number
How long have you lived here? (we need proof of this)
Can we contact you at your home address? /
Yes
/
No

If ‘NO’, please give an address or phone number where we can contact you and when is the best time to contact you?

Is anybody on your application expecting a baby / Yes / No

If ‘YES’, please give the name of the person and the date the baby is due. (Proof required)

Immigration Status

Is anybody on your application restricted by immigration rules / Yes / No

If ‘YES’, please give their name

Income details

Please tick the box that best describes you.
Working full time (over 16 hours) / Yes / No
Working part time / Yes / No
Looking after children or someone sick or elderly / Yes / No
Looking for a job / Yes / No
Pensioner or retired / Yes / No
Long term sick or disabled / Yes / No
Not looking for work / Yes / No
Full time student / Yes / No
Government training scheme / Yes / No
Other (please give details) / Yes / No

Please tick the box that best applies to you. Do not include Child Benefit, Housing Benefit and Council Tax Benefit.

Benefits
Income Support or Jobseeker’s Allowance or ESA / Yes / No
Wages/Employed (please give employers details below) / Yes / No
You
Address
Telephone Number
Working Families’ Tax Credit / Yes / No
Disability Living Allowance or Attendance Allowance / Yes / No
State retirement pension / Yes / No
Company pension / Yes / No
Other state benefits / Yes / No
Other (please give details) / Yes / No

Previous address

Please list the previous address of all the adults you have included in your application for re-housing, for the last five years. Start with the address you live at now

Name / Previous address / Dates from - to / Landlord

Which of the following best describes your situation?

Please tick one box in each column

Type of occupancy / Type of accommodation
Council tenant / House
Private tenant / Maisonette
Living in property I own / Flat
Housing association tenant / Bead and Breakfast
Living with friends or relatives / Hospital
Lodger / Bungalow
Hospital or residential home / Bedsit
In prison / Caravan or mobile home
Accommodation with job / Hostel
Member of armed forces / Sheltered or supported housing
Other (Please give details) / Other (Please give details)
Are you a tenant at your current home? / Yes / No
Are you an owner occupier at your current home? / Yes / No
Do you have an assured shorthold tenancy or a licence
(E.g. six month, 12 month)?
How many bedrooms do you have / 1 / 2 / 3 / 4 / 5
Have you ever been evicted?
/
Yes
/
No

If ‘YES’, give us the following information

The address you were evicted from
The landlord’s name
The reason you were evicted
The date you were evicted

Have you or anyone on your application, any criminal convictions for firearms offences or drug related offences?

If ‘YES’ please give details of the offences, including dates and sentences.

Reasons why you need re-housing

Tick the boxes that best describe why you need re-housing. (*Proof will be required)

Split up from partner / To get children into a better school
Losing home with job* / Neighbourhood problems
Landlord selling property* / Health reasons*
Want to move to a better area / Overcrowding
Victim of crime or fear of crime / Building Society repossession*
Need a smaller property / Asked to leave by friends or relatives
To leave home / Cannot afford present housing
To be nearer friends and family / Nearer current employment
Living apart from family / To give support
Eviction order* / To receive support
Poor condition of property / Need a larger home

Other (Please give details)

Are you suffering from harassment or domestic violence (Proof required) (attach separate sheet giving details if necessary) /

Yes
/
NO

Where do you want to live? (Tick as many boxes as you wish)

Liverpool 4 / Liverpool 13
Liverpool 4 / Liverpool 14 (2 Bed Flats only)
Liverpool 6 / Bootle L20
Liverpool 7 / Litherland L21

Liverpool 13

Please note the co-operative have very few properties in each area (See page 9)

How many bedrooms do you need?
/ 1 / 2 / 3 / 4 / 5

Declaration

Are you Board Member or an employee of Northwest Housing Services /
Yes
/
No
If ‘YES’ give details
Are you related to a committee member of Liverpool Gingerbread? /
Yes
/
No
If ‘YES’ give details

Data Protection Act

We register the information you give us on your housing application form in line with the Data Protection Act. We may share the information with other landlords or ask for references from your previous landlords. It is important that the information you give us is accurate. We may use certain information on your form to check the accuracy with the department of Work and Pensions, Police, Probation and Social Services Liverpool City Council (i.e. Supported Living and the Homelessness team) and other registered social landlords and private landlords or their agents.
In completing this form, you understand that in order to process your application we must share information you have provided with all the agencies identified mentioned within this application. All information which you have provided is processed in accordance with the Data Protection Act 1998 and the obligations which are placed on Data Controllers

Please Read & Sign the Declaration

As far as I know, the answers I have given on this form are true. I understand that I may lose any housing or tenancy if I have given false information. I understand that all the information I have given will be put on the landlord’s computer. I will tell the Co-op immediately if there is any change to the circumstances I have told you about in this form. I understand that by signing this declaration I am giving permission to contact any previous landlords and relevant agencies to check the information and release any relevant information. I agree to the information provided being shared with other housing agencies.

Your signature: / Date:

We may use information you have given on this form to analyse demand for our properties.

Please return your completed application form to:

Checklist

Proofs of Residence- we will require 2 proofs of residence for all adults listed and one proof for all children listed i.e. Child Tax Credit, if you are pregnant, you will need to provide a letter or a certificate from your doctor as proof. We will also require proof of National Insurance number – this information will be requested at the Home visit stage - DO NOT PROVIDE THIS INFORMATION WITH THIS APPLICATION

Some examples of proofs of National Insurance and residency we may need to see:

Benefit Agency letter / P60 / Recent paid Utility Bill
Child Tax Credit / National Insurance Card / Medical Card
Wage Slip / Bank Statement / Driving License

Equal opportunities monitoring form

We are committed to fighting discrimination and inequality in our service to the public. To help us monitor the success of our equal opportunities policy, it would be helpful if you could fill in this form. If you do not wish to fill in this form, it will not affect your application. We will not pass on the information you give us to anyone else, and will only be used to monitor, develop and improve our housing policies.

Please tell us your Nationality/Country
Of Origin by ticking the relevant box / You / Your Partner / Other
People
Asian
Caribbean
African
South East Asian
British European
Irish
Chinese
Yemeni
Travellers
Gypsies
Romanian
Polish
Other
Combination/Mixed race
Declined to answer
Only tick one box in each column / You / Your Partner / Other
People
Black
White
Other
Mixed Race
If you think that the categories above are not applicable, you can use this space to tell us why.
Religion / You / Your Partner / Other
People
None
Hindu
Sikh
Christian (include Church of England, Catholic, Protestant
And all other Christian denominations
Buddhist
Jewish
Muslim
Other
Prefer not to say

Please tell us if you or anybody else on your application is disabled

You / Your partner / Other people
Briefly describe the extent of your disability

Thank you for your help. This information will help us make sure we run our services fairly

Properties the co-op owns in

Liverpool 4 2 x 2 bedroom houses and 1 x 4 bedroom house

Liverpool 6 7 x 2 bedroom and 7 x 3 bedroom properties

Liverpool 7 9 x 3 Bedroom houses

Liverpool 13 6 x 2 bedroom houses and 1 x 3 bedroom house

Liverpool 14 3 x 2 bedroom flats

Bootle L20 1 x 2 bedroom house and 3 x 3 bedroom houses

Litherland L21 7 x 2 bedroom houses and 2 x 3 bedroom house

APPLICATIONS RECEIVED WITHOUT THE FOLLOWING INFORMATION MAY BE REJECTED

1  We require the previous address history for the past 5 years for all adults listed on the application and the names/addresses of all tenants/owners and landlords if applicable

2  Liverpool Gingerbread Housing Co-operative requires References from all landlords that the home seekers have rented from within the last 5 years.

3  Copies of Notice to Quit are required where a notice has been served

4  Letters of support from any homeless units, domestic violence units, the Probation Service etc were applicable

5 Medical conditions must be supported by Doctors/Hospital certificate

Please note Liverpool Gingerbread Housing Co-operative is a lone parent organisation

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