housing application form

Please answer ALL the questions on the form, they are all relevant to determining your application. For every applicant, include at least two forms of proof of identity and proof of current address.

Failure to answer all the questions and providing the necessary proofs could lead to a delay in us dealing with your application.

Forms of identifi cation include Proof of current address include

Full birth certifi cate Recent Bank Statement

Medical card Council Tax Bill

Marriage certifi cate TV Licence

Driving licence Recent Utility Bill (eg. Gas / Electricity /Telephone but not Mobile phone)Passport

Proof of Benefi t entitlement Tenancy Agreement

For every child included on the application form we will need proof of child tax credit.

We must see the original documents, photocopies will not be acceptable.

When completed please return this form to:

Providing Access for All - Please see statement on Page 26

Housing ServicesSherwood LodgeBolsoverDerbyshireS44 6NF

Tel: 01246 242424Email: [email protected]: www.bolsover.gov.uk

APPLICATION FOR HOUSING

Name

Number

or any of our Contact Centres, please see address on Page 19.

SECTION A YOU AND YOUR HOUSEHOLDAPPLICANT JOINT APPLICANT

Mr Mrs Miss Ms

Present address:

Post Code:

Correspondence address (if different from above)

Post Code:

Date of Birth: / /

Village / Town of Origin:

First Name(s):

Surname:

National Insurance No. :

Single Married

Separated Divorced

Widowed Living

together

Home Tel. No. :

Work Tel. No. :

Mobile Tel. No. :

EMail Address :

Mr Mrs Miss Ms

Present address:

Post Code:

Correspondence address (if different from above)

Post Code:

Date of Birth: / /

Village / Town of Origin:

First Name(s):

Surname:

National Insurance No. :

Single Married

Separated Divorced

Widowed Living

together

Home Tel. No. :

Work Tel. No. :

Mobile Tel. No. :

EMail Address :

:Relationship to applicant one eg. spouse, child, partner etc.

Length of time at current address :Length of time at current address :

Other - please state

Other - please state

Have you, your partner / joint applicant ever been known by another name?

Yes No

If yes, please give details:

Please list everyone wishing to be rehoused with you (including children)

Full name Sex(M/F)

Date of birth

Age Relationship toapplicant

Currently living withapplicant (tick)

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

If anyone included in the application lives at a different address, please enter their details below:

Full name Address Reason for living apart

Please give details of anyone who shares your accommodation at present but is not to be rehoused with you:

Surname First name Relationship Date of birth

If you have access to children, please give these details and provide proof of access for example, joint residency order, letter from solicitor, letter from ex-partner:

Childs name Age Date of birth Number of days access each week

Address:

Post Code:

Is anyone wishing to be rehoused expecting a baby? Yes No

Name of Person Date when baby is due

PLEASE ATTACH A COPY OF YOUR CERTIFICATE CONFIRMING PREGNANCY. ALSO PROVIDE A COPY OF BIRTH CERTIFICATE WHEN CHILD BORN

/ /

EMPLOYMENT AND INCOMEAPPLICANT JOINT APPLICANT

Occupation :

Employer :

Working full time

Working part time

Government training / New Deal

Job Seeker

Retired

Full time student

Unable to work

Carer

Number of hours worked :

Continued overleaf ......

Address:

Post Code:

Occupation :

Employer :

Working full time

Working part time

Government training / New Deal

Job Seeker

Retired

Full time student

Unable to work

Carer

Number of hours worked:

Do you currently claim any benefits?

Yes No

If yes, what benefits do you claim?Please list all below:

Name Address Relationship

Do you have any close relatives living in the Bolsover District Council area? Yes NoIf yes please specify

SECTION B WHERE YOU LIVE NOW

Please list all of your previous addresses during the last 10 years. Please start with your present address:

APPLICANTAddress Please indicate if

Council or Housing Association, Private Tenant, Owner Occupier or Other

Dates From / To Reason for Leaving

JOINT APPLICANT

Do you have any of the following in your present accommodation? (please tick):

A bedroom

A bathroom

Inside toilet

Outside toilet

Hot water

Mains cold water

Kitchen (including cooking facilities)

Living room

Steps at front

Steps at rear

None Sole Use Shared Is shared with whom

Means of heating

Are you : (please tick only one)

A council tenant

A housing association tenant

An owner occupier

An owner occupier (low cost home

ownership)

A private tenant

In tied housing

In supported housing

In a probation hostel

In a residential care home

Living with family

Living with friends

Home office asylum support

Other

In hospital

In housing for older people

In prison

In any other temporary

accommodation

In a foyer

In short life housing

In a mobile home/caravan

In a refuge

In a direct access hostel

In bed & breakfast

Rough sleeping

Childrens home/foster care

APPLICANT JOINT APPLICANT

Are you : (please tick only one)

A council tenant

A housing association tenant

An owner occupier

An owner occupier (low cost home

ownership)

A private tenant

In tied housing

In supported housing

In a probation hostel

In a residential care home

Living with family

Living with friends

Home office asylum support

Other

In hospital

In housing for older people

In prison

In any other temporary

accommodation

In a foyer

In short life housing

In a mobile home/caravan

In a refuge

In a direct access hostel

In bed & breakfast

Rough sleeping

Childrens home/foster care

If applicable, please give details of expected discharge date or release date and any arrangements made thereafter

If private rented tenant or housing association tenant please give name and address of landlord and a copy of your tenancy agreement

INFORMATION ABOUT YOUR HOME

What type of property do you live in? (tick one box) :

House Bungalow Sheltered housing

Flat Hostel Boat

Bedsit Caravan Mobile home

Maisonette B&B Sleeping rough

Other (please give details):

Does your property suffer from any disrepair which in your view affects your quality of life?

Yes No

If yes please give details:

You are overcrowded

Property unsuitable for medical reasons

Affordability - mortgage / rent too high

To move nearer work

To move to independent accommodation

Assured shorthold tenancy has ended

Domestic violence

Asked to leave by family or friends

Problems with neighbours

Discharged from prison / long stay hospital

Other (please give details in box overleaf )

Why do you want to move? (you can tick more than one box)

Your property is too large for your family

Property is in poor condition

To move nearer to family/friends/school

To move to accommodation with support

Loss of tied accommodation

Eviction or repossession

Relationship breakdown with partner (non violent)

Harassment - racial/disability/gender/transgender/sexual orientation

Left home country as refugee

Decanted by Bolsover District Council to another property

How many bedrooms does your current property have?

Ground FloorFirst Floor



Other Properties

Do you or your partner own or have a fi nancial interest in any property that you are not living in?

Yes No


Do you have any pets? Yes No

If yes please tell us what type and how many:

SECTION C HEALTH & SOCIAL FACTORSMedical FactorsSocial problems such as diffi culties with neighbours or the dislike of the locality cannot be considered to be medical problems. Please give brief details of any relevant health problems that affect you or any member of your household. A further questionnaire will be issued to ascertain your medical priority:

Please describe how these medical problems are affected by your present home, eg unable to get upstairs, diffi culty using bathroom etc.

Has your present home been provided with adaptations, eg ramp, shower etc? Yes No


Do you consider yourself or any member of your household to be disabled? Yes No(For a defi nition of Disabled please see page 15)

Do you need to move to give / receive support for health reasons? Yes No

If yes please give details, including name and address of people concerned:

Do you have a GP, social worker, health or other advocate who can add support to your housing application if requested:

Yes No

If yes please give details :

Do you have a ....? Name Contact Address Tel. Number

Social Worker

Probation Offi cer

Health Visitor

Community Psychiatric Nurse

Connexion Personal Advisor

Is anyone helping you to be rehoused

SOCIAL NEEDS FACTORS

Points may be awarded to applicants who may come to harm or whose welfare is at risk in their current accommodation. Please tell us if you or anyone included in your application would qualify for these points and why. We will need you to substantiate all claims before points are awarded.

Have you previously been evicted from a property owned by a local authority, housing association or private landlord?

Yes No

If yes please give details of address and reason:

IMMIGRATION STATUS

Have you resided in the United Kingdom for the past 5 years?

Yes No

If no please give details:

CONVICTIONS

Have you or any other person normally residing with you or who will be residing with you, ever been convicted or have any prosecutions pending for any criminal offence?

Yes No


Has a landlord ever started action against you or your household for anti social behaviour?

Yes No


SECTION D GENERAL INFORMATIONFailure to complete both pages 13 and 14 completely could result in your application for rehousing not being considered.

NATIONALITYAPPLICANT JOINT APPLICANT

Have you lived in another country in the last fi ve years?

Yes No

Austria Latvia

Belgium Lithuania

Cyprus Luxembourg

Czech Republic Malta

Denmark Netherlands

Estonia Poland

Finland Portugal

France Slovakia

Germany Slovenia

Greece Spain

Hungary Sweden

Ireland Other - Where?

Italy

/ /When did you come to live in this country?

D D M M Y Y Y Y

What is your nationality?

Have you lived in another country in the last fi ve years?

Yes No

Austria Latvia

Belgium Lithuania

Cyprus Luxembourg

Czech Republic Malta

Denmark Netherlands

Estonia Poland

Finland Portugal

France Slovakia

Germany Slovenia

Greece Spain

Hungary Sweden

Ireland Other - Where?

Italy

/ /When did you come to live in this country?

D D M M Y Y Y Y

What is your nationality?

How would you describe your sexuality?

Heterosexual Gay Lesbian

Bisexual Prefer not to say

How would you describe your sexuality?

Heterosexual Gay Lesbian

Bisexual Prefer not to say

EQUAL OPPORTUNITIES MONITORING FORM

APPLICANT JOINT APPLICANT

This section is not relevant in determining your application, however completion of the relevant details will help us to ensure we are providing a fair service.

DisabilityThe defi nition of Disability in the Disability Discrimination Act 1995 is A physical or mental impairment which has substantial and long term adverse effect on a persons ability to carry out normal day to day activities.

Do you consider yourself to be disabled?

Yes No

If yes, what are your impairments? Please tick all that apply.

Mobility Visual

Speech Hearing

Wheelchair user Learning Disability

Mental Health Long Standing condition inc. Health Condition Depression eg. Cancer, HIV

Other - Please State

Do you consider yourself to be disabled?

Yes No

If yes, what are your impairments? Please tick all that apply.

Mobility Visual

Speech Hearing

Wheelchair user Learning Disability

Mental Health Long Standing condition inc. Health Condition Depression eg. Cancer, HIV

Other - Please State

Please tick the appropriate box to indicate your cultural background :

A. White C. Asian or Asian British

British Indian

Irish Pakistani

Polish Bangladeshi

Italian Other

Other

B. Mixed D. Black or Black British

British Caribbean

White & Black African Caribbean Other

White & Black African E. Other Ethnic Group

White & Asian Chinese

Other Gypsy

Dual heritage

Other

Please tick the appropriate box to indicate your religion or beliefs:

None Buddhist Christian

Hindu Jewish Muslim

Sikh Other Prefer not to say

Please tick the appropriate box to indicate your cultural background :

A. White C. Asian or Asian British

British Indian

Irish Pakistani

Polish Bangladeshi

Italian Other

Other

B. Mixed D. Black or Black British

British Caribbean

White & Black African Caribbean Other

White & Black African E. Other Ethnic Group

White & Asian Chinese

Other Gypsy

Dual heritage

Other

Please tick the appropriate box to indicate your religion or beliefs:

None Buddhist Christian

Hindu Jewish Muslim

Sikh Other Prefer not to say

OTHER HOUSING OPTIONSMutual ExchangeCouncil and Housing Association tenants may exchange properties providing they have written permission from their landlords. The mutual exchange list is a way of fi nding someone to exchange with. If you apply, the details about your property will be displayed on the mutual exchange list on the Internet and in designated locations.

If you are interested please tick in the box provided

Shared OwnershipShared ownership requires the applicant to buy a share of the price of a particular Housing Association property (normally half ) and rent the remaining share from the Housing Association. The owned share can be gradually increased until the whole property is bought. If you are interested please tick in the box provided

Do you want to be considered for nomination to a Housing Association?

Yes No

Do you want to be considered for nomination to a private landlord?

Yes No

If you have answered yes to the above, we will need to share your information with other housing providers. Please tell us if you dont want us and where it with a specifi c organisation. Please refer to mean data protection statement on page 17.

DECLARATION

Do you wish to give authorisation for someone to act on your behalf, for example, social worker, support agency worker, family member. Please give name and contact details.

FOR THE ATTENTION OF ALL APPLICANTSIMPORTANT NOTICE - HOUSING ACT 1996 - s.171 & s.214 - FALSE STATEMENTSWhere a person approaches the Housing Department seeking an allocation of housing or claiming to be homeless or threatened with homelessness, the above Act makes it an offence, punishable with a fi ne, for a person to make a false statement or to withhold information which is relevant to their claim. For homeless applicants it is also an offence to fail to inform the housing authority of any material changes in circumstances which may occur between the initial interview and such time as notifi cation of the Councils decision is received.

NATIONAL FRAUD INITIATIVENOTIFICATION TO DATA SUBJECTS (HOUSING RENTS)The authority is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes. For further information see www.bolsover.gov.uk/national-fraud-initiative.html or contact Mr John Brooks CPFA, Director of Resources 01246 242431.

FOR THE ATTENTION OF ALL APPLICANTSDECLARATIONThe information I provide is accurate. I understand that if I obtain accommodation by providing inaccurate information, the Council may take legal action to recover the property.

Signature of applicant Date

Signature of joint applicant Date

I am an officer or member of Bolsover District Council or have been within the last 10 years.

I am a close relative / close friend of an officer or member of Bolsover District Council. Please give name of officer/member

None of the above apply to me

If you are a relative / close friend of an officer or member, please state their name and the nature of your relationship. (eg. son, daughter etc.)

Name Relationship

All personal information provided to Bolsover District Council will be held and treated in confi dence in accordance with the Data Protection Act 1998. It will only be used for the purpose for which it was given and may be shared with other council departments or third party organisations.

WHAT ACCOMMODATION DO YOU NEED?

The type and size of accommodation that you may be offered will depend on the size of your family. Please refer to the Bolsover District Council - Choice Based Letting Information Booklet for details of what you may be eligible for.

Would you accept any type of property as long as it is suitable for your needs?

Yes No

If NO, please tick the type(s) of property you would accept. Please note: If you are in a priority group you may be offered any type of property suitable for your needs.

House Bungalow

Sheltered Flat Sheltered Bedsit

Ground Floor Flat Housing with support

First Floor Flat

How many bedrooms do you want?

You cannot ask for a property larger than your family needs. You can ask for a smaller property (for example, one bedroom less) with some exceptions.See the Choice Based Letting Information Booklet for further details.

CONTACT CENTRE AREAS WITH VILLAGES

BlackwellHilcoteNewtonPinxtonSouth NormantonTibshelfWesthouses

LangwithLangwith JunctionShirebrookWhaley Common

Villages

Villages

Shirebrook Contact Centre Area2a Main Street, Shirebrook, Notts

VillagesBarlboroughClowneCreswellHodthorpeWhitwell

VillagesBolsoverBramley ValeDoe LeaGlapwellHillstownNew HoughtonPaltertonShuttlewoodScarcliffeStanfree

OPENING TIMESOffi ce Opening Times9.00am -5.00pm Monday - Friday 9.00am - 12.30pm Saturday

Telephone Lines8.00am -5.00pm Monday - Friday 9.00am - 12.30pm Saturday

Clowne Contact Centre Area9 Church Street, Clowne, Derbyshire

Bolsover Contact Centre AreaSherwood Lodge,Bolsover

South Normanton Contact Centre Area124a Martket Street, South Normanton, Derbyshire

Please tick the box next to the town/villages where you would accept an offer of housing.Please note however that some villages have limited availability.

Barlborough

Blackwell

Bolsover

Bramley vale

Clowne

Creswell

Doe lea

Glapwell

Hilcote

Hillstown

Hodthorpe

Langwith

Langwith junction

New houghton

Newton

Palterton

Pinxton

Scarcliffe

Shirebrook

Shuttlewood

Stanfree

South normanton

Tibshelf

Westhouses

Whitwell

Please rank from the above town/villages your top three preferred areas:

First:

Second:

Third:

ADDITIONAL INFORMATIONPlease use this space to provide any other information which you feel may be relevant to your application.

OFFICE USE ONLY

Date Information Initials

Identifi cation verifi ed

Eligibility

Check for written off arrears

Rent - current FTA

Sundry Debts / recharges

Registration card issued

This section is not mandatory and is not relevant to determining your application for housing. This information below is about where you would like to live and in what type of property. It is not current property availability but will help our Strategy Team when considering what types of accommodation we will need in our district in the future.

Please tick the area you would like to live in:

Clowne Contact Centre AreaBarlborough

Clowne

Creswell

Elmton

Hodthorpe

Mastin Moor

Shirebrook Contact Centre Area

Langwith

Langwith Junction

Pleasley

Shirebrook

Bolsover Contact Centre AreaAstwith

Carr Vale

Bolsover

Bramley Vale

Doe Lea

Glapwell

Hillstown

South Normanton Contact Centre Area

Blackwell

Broadmeadows

Hardstoft

Newton

Pinxton

AREA AND PROPERTY TYPE PREFERENCE

Please tick the type of accommodation you would prefer if available:

0 bed 1 bed 2 bed 3 bed 4 bed 4+bed

House n/a

Flat ground fl oor n/a

Flat above ground fl oor n/a

Bungalow n/a

Sheltered accommodation n/a

Bedsit n/a n/a n/a n/a n/a

Social Rented

Shared Ownership

Renishaw

Spinkhill

Steetley

Whitwell

Whitwell Common

New Houghton

Palterton

Scarcliffe

Shuttlewood

Stanfree

Stoney Houghton

Upper Langwith

Whaley

Whaley Thorns

South Normaton

Stainsby

Tibshelf

Westhouses

WHAT TO DO NOW

Please check that you have . . .Filled in and signed the application form for yourself, a joint applicant and other members of your household, if applicable.Included the required proof of identity and proof of address. Checked the price of posting this form and any other supporting proof, if you are sending it through the post. Failing to put the correct postal price on your envelope may result in applications not being received and processed.

When we get your housing application:We will let you know we have received it within three working days. We will write to you within five working days of receiving it if we need any further information or proof. We will contact you within ten working days if we need to arrange an interview at your home or nearest Contact Centre. We will contact you within twenty working days to confirm that your application is active or registered (started to be used)

If we can not start your application within 20 working days, we will write and tell you why. The delay may be because we need more information from you or another agency.

Confi rmation of Application ReceiptI acknowledge receipt of your housing application received.If we require any further information you will be contacted within 5 working days. You will receive confi rmation within 20 working days that your application is active or registered.If you have any questions relating to your housing application.

PROVIDING ACCESS FOR ALL If you need help understanding any of our documents or require a larger print, audio tape copy or a translator to help you, we can arrange this for you. Please contact us on the telephone numbers at the bottom of the page: POLISH Jeeli potrzebuje Pan/i pomocy w rozumieniu tych dokumentw lub chciaby je Pan/i otrzyma wikszym drukiem, na kasecie audio lub skorzysta w tym celu z pomocy tumacza, jestemy to Pastwu w stanie zapewni. Prosimy o kontakt pod numerami telefonw na dole strony. ITALIAN Se avete bisogno di aiuto per capire qualsivoglia dei nostri documenti o se li richiedete a caratteri grandi, o volete copie registrate, o necessitate di un traduttore per aiutarvi, noi possiamo organizzare tutto ci. Per favore contattateci ai numeri di telefono che troverete in fondo a questa pagina. CHINESE URDU

01246 242407 or 01246 242353. Other Equalities information is available on our web site. www.bolsover.gov.uk or by e-mail from [email protected] Minicom: 01246 242450 Fax: 01246 242423

housing application form

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