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Page 1
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.
Page 2
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
Page 3
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
Page 4
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:
Page 5
Name Address Relationship
Do you have any close relatives living in the Bolsover District Council area? Yes NoIf yes please specify
Page 6
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
Page 7
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
Page 8
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
Ground FloorFirst Floor
Ground FloorFirst Floor
Page 9
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
If yes please give details:
Do you have any pets? Yes No
If yes please tell us what type and how many:
Page 10
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
If yes please give details:
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)
Page 11
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
Page 12
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.
Page 13
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
If yes please give details:
Has a landlord ever started action against you or your household for anti social behaviour?
Yes No
If yes please give details:
SECTION D GENERAL INFORMATIONFailure to complete both pages 13 and 14 completely could result in your application for rehousing not being considered.
Page 14
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
Page 15
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
Page 16
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.
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.
Page 18
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.
Page 19
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
Page 20
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:
Page 21
ADDITIONAL INFORMATIONPlease use this space to provide any other information which you feel may be relevant to your application.
Page 22
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
Page 23
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
Page 24
Page 25
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.
Page 26
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