Housing Application Form Housing Application Form 1. Applicant’s DetailsName:(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Title First Last Address:(Required) Street Address Address Line 2 City Postcode Phone:(Required)Other Contact No:Email: National Insurance No:(Required)Date of Birth:(Required) DD slash MM slash YYYY 2. Have you applied to Hull Churches for housing before? Yes No 3. Are you considering joint tenancy with someone else? Yes No 4. If yes, what are the second applicant’s details?Name:(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Title First Last Address:(Required) Street Address Address Line 2 City Postcode Phone:(Required)Other Contact No:Email: National Insurance No:(Required)Date of Birth:(Required) DD slash MM slash YYYY 5. Other than yourself or applicant 2 (if applicable), who else will be living in the property?Name: Dr.MissMr.Mrs.Ms.Prof.Rev. Title First Last Date of Birth: DD slash MM slash YYYY Relationship:National Insurance No:Name: Dr.MissMr.Mrs.Ms.Prof.Rev. Title First Last Date of Birth: DD slash MM slash YYYY Relationship:National Insurance No:Name: Dr.MissMr.Mrs.Ms.Prof.Rev. Title First Last Date of Birth: DD slash MM slash YYYY Relationship:National Insurance No:Name: Dr.MissMr.Mrs.Ms.Prof.Rev. Title First Last Date of Birth: DD slash MM slash YYYY Relationship:National Insurance No:How many bedrooms do you require:(Required)Reason:(Required)Is anyone mentioned above expecting a baby? (including yourself) Yes No Are you, or anyone mentioned above related to a member of HCHA staff or board? Yes No What pets do you have, if any?(Required)How many cars does your household have?(Required)Income – Applicant 1Are you working at the moment?(Required) Yes No If yes, what is your Salary / Wage amount:Timeframe: Per Week Per Month Per Year If not working, do you receive benefits?(Required) Yes No What type of benefits do you receive?Benefits amount:Timeframe: Per Week Per Month Per Year Do you get Housing Benefit at the moment?(Required) Yes No If yes, do you get Full or Part Housing Benefit? Part Housing Benefit Full Housing Benefit Amount of Housing Benefit:Timeframe: Paid Per Week Fortnightly Four Weekly Do you have any savings? If yes, how much are your savings?(Required)Income – Applicant 2 (if applicable)Are you working at the moment?(Required) Yes No If yes, what is your Salary / Wage amount:Timeframe: Per Week Per Month Per Year If not working, do you receive benefits?(Required) Yes No What type of benefits do you receive?Benefits amount:Timeframe: Per Week Per Month Per Year Do you get Housing Benefit at the moment?(Required) Yes No If yes, do you get Full or Part Housing Benefit? Part Housing Benefit Full Housing Benefit Amount of Housing Benefit:Timeframe: Paid Per Week Fortnightly Four Weekly Do applicant 2 have any savings? If yes, how much are your savings?(Required)Income other members of your household (if applicable)Name:Relationship to Applicant 1:Salary / Wage:Time frame: Per Week Per Month Per Year Benefits:Time frame: Per Week Per Month Per Year Name:Relationship to Applicant 1:Salary / Wage:Time frame: Per Week Per Month Per Year Benefits:Time frame: Per Week Per Month Per Year OutgoingsPlease give details of any (all) outgoings below:Rent / Mortgage:Utility Bills:Council Tax:Property Insurance:Child Maintenance:Other: (please specify)Other: (please specify)Other: (please specify)Do you have any other income or outgoings we should know about? If yes, please provide details:Why you want to movePlease tick ALL boxes that apply:(Required) Domestic violence Subject to harassment / abuse Relationship breakdown About to be made homeless Leaving hostel Unsuitable property / location Non-secure accommodation Setting up home Needing major repair Needing a smaller property To have more affordable accommodation Sharing with others Urgent health / disability Medical condition To receive support from someone To give support to someone To be nearer to shops / facilities To move closer to friends / family Access to employment Other. Please explain below Other Information:Please use this place if you wish to provide any additional information you feel is relevant to your application. i.e. health and medical circumstances, cultural and religious needs, details or current circumstances, why you want to move:Local connections with the area you want to live inPlease give us details of any local connections with the area you want to live in e.g schools/workWhere you live nowUnder HCHA charitable ‘rules’ we need to consider whether circumstances such as a low income or particular health or support needs would make other housing options (such as buying a home) unviable. This does not disbar current homeowners who need to sell their home, and because circumstances can change, we do not have any set limit.If you own your home: (we may request that you obtain evidence of approximate worth and mortgage statement)Do you own your own home?(Required) Yes No How much is your home worth? (approximately)(Required)How much mortgage is outstanding?(Required)We may also need to check with other organisations, including your current landlord. Examples of information we will check include any unpaid rent arrears or legal notices relating to your current property condition or any unspent criminal convictions that indicate potential risk to our existing tenants, employees or contractors. The existence of rent arrears will not disbar an applicant from receiving an offer; however, HCHA reserves the right to establish what arrangements have been made between the applicant and current landlord, and if the arrangement has been adhered to, and we may take this into account in determining whether an offer of accommodation can be made, in accordance with the current housing regulations.If your rent your home, please tell us about your landlord below:Landlord’s name:Landlords address: Street Address Address Line 2 City Postcode Your health & mobilityAre you wanting to move because of health and/or mobility reasons?(Required) Yes No Don't know Are specialist services/disabled adaptations provided in your current home?(Required) Yes No Don't know If yes, do you need these services/ adaptations provided?(Required) Yes No Don't know Please tell us about the service(s) provided below, or any you have applied for:For health or mobility reasons, do you require level floor accommodation?(Required) Yes No Don't know Are you able to climb stairs?(Required) Yes, 1 flight of stairs is OK Yes, 2 flights of stairs or more are OK No, I would need lift access No, I would need ground floor accommodation Do you, or anyone else moving with you, use a wheelchair?(Required) Yes No Do you, or anyone else moving in with you use a mobility aid such as a rollator or mobility scooter?(Required) Yes No Registered disabilitiesDo you, or anyone else moving with you have a disability?(Required) Yes No Is that person registered as having a disability? Yes No Registration Number:Please give details of medical circumstances you wish Hull Churches to consider:Do you receive any other type of support from Social Services, Health Authority, Voluntary Agencies or any other such agency?(Required) Yes No Please give details of support:How you can help usTo support your application, please enclose any of the following which may apply to you. You are welcome to send information after the form has been returned, but your application will be put on hold until we receive any supporting documents.Medical Support from your GP or consultant:Max. file size: 128 MB.Medical Priority letter from the district medical officer:Max. file size: 128 MB.Court Order:Max. file size: 128 MB.Repossession Notice:Max. file size: 128 MB.Letter of Support from your Key Worker:Max. file size: 128 MB.Letter of Support from your Neighbourhood Mental Health Team:Max. file size: 128 MB.Proof of Acceptance onto the Homeless Register:Max. file size: 128 MB.Supporting information from schools:Max. file size: 128 MB.Other:Max. file size: 128 MB.Criminal Convictions Declaration: everyone MUST fill in this partDo you, or anyone else included in this form, have criminal convictions which are not spent?(Required) Yes No Name of offender:Date of conviction: DD slash MM slash YYYY Offence:When will it be spent?Name of offender:Date of conviction: DD slash MM slash YYYY Offence:When will it be spent?Property Locations & How Our Properties Are AllocatedAll our properties are located in Hull and the East Riding. Our Tenancy Services Team assesses each application individually and scores your application based on the answers you have given. You will receive a letter in due course informing you whether you have been accepted onto our waiting list, or if not, the reason why. If you are accepted onto our waiting list, your letter will inform you how many points you have been awarded and why. If, for any reason, your circumstances change which you believe will affect how many points you have been allocated, please contact us. We review our waiting list periodically, so you may be asked to complete further forms to assist with your application.If you have specific reasons for preference of areas, please give details below:We will take your reasons into consideration; however this may impact on how long you would be waiting.Declaration by applicantThe information given on this application is a true statement. I understand that Hull Churches Housing Association Ltd will verify the information on this form and may check it with, or pass it on to, organisations such as current or former landlords, social services, doctors, hospitals, banks, building societies, credit reference agencies, police, probation service, support agencies or any organisation they feel necessary in line with their Fair Processing Notice. By signing this form, I am giving permission for Hull Churches Housing Association to obtain any further information they may need. I understand that Hull Churches Housing Association Ltd reserve the right to take action for possession of any accommodation if it has been obtained by deliberately providing false information. Please note we will not request a reference from your current landlord without speaking to you first.Name:(Required) First Last Date:(Required) DD slash MM slash YYYY If your address or circumstances change in the future, please let the office know. Please make sure all the questions are answered fully.Declaration by a person completing this form on behalf of the applicantIf another person is completing this form on the applicant’s behalf, they must also provide the following details:Name: First Last Address: Street Address Address Line 2 City Postcode Phone:Email: Relationship to applicant:Why you are completing this form on behalf of the applicant: Δ
