Housing. Application Form

Transcription

1 Housing Application Form

2 Rykneld Homes Housing Application Form If you need any help to complete this form please get in touch with the Choice Move Team on or go to one of our housing offices listed below. You must complete this form if you want to apply for a home with North East Derbyshire District Council (NEDDC) which is managed by Rykneld Homes, or any other of NEDDC/Rykneld Homes partner landlords (Housing Associations). If you want to rent a property, we will use the information you give us to award you a band this shows the housing need that best reflects your circumstances. You can find more information about Choice Move by visiting our website or by contacting the Choice Move Team on Before you fill in this form, please answer the following question: Are you currently a North East Derbyshire District Council tenant? Yes No If you are currently a tenant, you may wish to register on the HomeSwapper site. This is where our tenants can swap with other NEDDC, housing association or local authority tenants. You can register at If you are unsure, please contact us to find out if you need to go on Homeswapper. Notes and Guidance: We cannot register your housing application if you do not answer all the questions on the form that apply to you and any other person moving with you. You will also be asked to provide proofs relevant to your household and your housing circumstances to ensure you are eligible for housing and to support your application. Acceptable forms of ID: Passport, Driving Licence, Medical Card, Full Birth Certificate, Marriage Certificate, Benefits Award Letter The original copies of all supporting documents must be seen by a member of Rykneld Homes or North East Derbyshire District Council staff. You can help us by ensuring that you write as clearly as possible so we can read your information correctly. Please make sure that you put a tick (3) inside any boxes where you have to select an answer from a list of options. The application can be returned to any of the following offices: District Council Offices, 2013 Mill Lane, Wingerworth, Chesterfield, S42 6NG Clay Cross Housing Office, Market Street, Clay Cross, Chesterfield, S45 9JE Dronfield One Stop Shop, Dronfield Sports Centre, Civic Centre, Dronfield, S18 1PD Eckington Housing Office, Eckington Swimming Pool, Eckington, S21 4DA Killamarsh Housing Office, Stanley Street, Killamarsh, S21 1EL North Wingfield One Stop Shop, Community Resource Centre, Whiteleas Avenue, North Wingfield, Chesterfield, S42 5PW When we get your completed application we will acknowledge receipt of it. We will then contact you within 14 days of receiving a completed application to advise you if your application has been successful. We will also include information and guidance on how to bid for available properties. 2 Housing Application Form

3 Information about you 1 Personal Details Please provide one form of identification, proof of National Insurance Number and proof of current address for each applicant. If you are homeless and staying with family/friends you will need to provide letters from them confirming you stay there. Your Household Main Applicant Joint Applicant Title Mr Mrs Miss Ms Mr Mrs Miss Ms Other: Other: Surname First Name(s) Previous Name(s) Please tell us if you have ever been known by any other name(s) National Insurance Number Date of Birth (dd/mm/yyyy) Are you male or female? male female male female Marital Status single married single married Relationship to Main Applicant (for joint applicant only) (e.g. spouse, parent, partner, child etc) Current Address divorced co-habiting divorced co-habiting separated widowed separated widowed When did you move to this address? (dd/mm/yyyy) Housing Application Form 3

4 Information about you Contact Details Main Applicant Joint Applicant for contact preference Home Number: Mobile Number: Work Number: Other, please specify: Mailing Address (If you want us to post letters to a different place than your home address, Personal please Details tell us here. If you are homeless you need to give your care of address here.) 2 Please provide proof of indefinite leave to remain in the UK. Nationality Main Applicant Joint Applicant What is your nationality? Have you lived in any other country in the last 5 years? If yes, where? Do you, or anyone moving with you, own a property in another country? If yes, please provide details. Yes No Yes No Yes No Yes No If you are British, please move to page 5. If Personal you are Details any other nationality please complete the sections below. When did you move to this country? Do you have indefinite leave to remain in the UK? Are you an asylum seeker or refugee? Did you enter the UK on a sponsorship undertaking? Yes No Yes No Yes No Yes No Yes No Yes No 4 Housing Application Form

5 People moving with you Please use the table below to list any other people who you want to include on your housing application. This includes partners, children, other relatives and friends. Please do not include yourself (main applicant) or the joint applicant. If you have access to any children the section relating to this is on page 6. 1 Please provide one form of identification, proof of National Insurance Number, income and bank statement and proof of address for anyone over the age of 16. Please provide the full birth certificate (this must show parents names), child benefit or tax credit award letter (this must show child s name) for anyone under the age of 16. First Name Surname Relationship Gender Date of National Living with to Main Birth Insurance you now? Applicant Number M F Yes No M F Yes No M F Yes No M F Yes No M F Yes No If any of the people moving with you do not currently live with you please provide their address(es) here: Personal Details 2 You must provide proof of any pregnancy, this must show the due date. PROOF Are you or anyone moving with you pregnant? Yes No Name of person who is pregnant: When is the baby due? (dd/mm/yyyy): 3 PROOF Please provide details of anybody in your current home that will NOT be re-housed with you. First Name Surname Relationship to you Gender Date of Birth M F M F M F M F Housing Application Form 5

6 People moving with you 4 Access Details This section deals with any access you have to children. This can be access that is mutually arranged with another parent/guardian or access that is granted through the courts. Please note, we will contact the parent/guardian of the child/children to confirm these details. this. Please provide the full birth certificate for each child (showing parent s names). If you are not their parent, please provide documentation confirming that you are a legal guardian. If you have legal access to the child/children, please provide the court papers showing First Name Surname Relationship Gender Date of Stay Will stay If yes, to you Birth overnight overnight how many now? when you nights per move? week? M F Y N Y N Please provide the following details for each child: Personal Details M F Y N Y N M F Y N Y N Name Current Address Parent/Guardian Parent/Guardian Name Contact Number 6 Housing Application Form

7 Where you live now 1 Current Address Details Please tick one of the following that best describes the type of home you live in now (tick list) If you currently rent your property, please provide your tenancy agreement. Please note, tenants of North East Derbyshire District Council are not required to provide their tenancy agreement. North East Derbyshire District Council T enancy Housing Association Tenancy Other Local Authority Tenancy Private Tenancy Owner Occupier Living with Friends Living with Family Bed & Breakfast Supported Housing Main Joint Applicant Applicant Care Home Hospital Hostel Prison/Youth Offending Institute Lodger Mobile Home Caravan No Fixed Address Sleeping Rough Main Joint Applicant Applicant Armed Forces Tied Accommodation Other, please specify: 2 What Type of Building is your current home? House Main Joint Applicant Applicant Bungalow Main Joint Applicant Applicant Maisonette Bedsit Upper Floor Flat Sheltered Accommodation Ground Floor Flat Mobile Home/Caravan Other, please specify: How many steps do you have to climb from the pavement to enter your property? Number of steps to: Front Door Back Door Main Joint Applicant Applicant Housing Application Form 7

8 Where you live now 3 Adaptations in the property? Please tick all the adaptations that are in your current property Main Joint Main Joint Applicant Applicant Applicant Applicant Grab Rails Stairlift Extra Handrail Widened Doors Ramp Wheelchair Accessible Wet Room/Level Access Shower Other, please specify: If you have any of these adaptations, please confirm who these were installed for/used by: Name: 4 What rooms do you have in your current property? Living Room Main Joint Applicant Applicant Conservatory Main Joint Applicant Applicant Dining Room Bathroom Kitchen Bedrooms Other, please specify: How many bedrooms do you have in 5 Main Applicant your current property? Joint Applicant 6 Are there any basic amenities that you do not have in your current home? Please tick if in your current property you have, do not have or share the following facilities with someone who is not part of your household Facilities Have Do Not Share Facilities Have Do Not Share Have Have Any form of heating Kitchen Fixed Bath/Shower Main Joint Main Joint Main Joint App. App. App. App. App. App. Hot/Cold Water Inside WC Other, please specify: Main Joint Main Joint Main Joint App. App. App. App. App. App. 8 Housing Application Form

9 Landlord s Details 1 If you are currently renting your home please provide your landlord s details: Landlord Name: Main Applicant Joint Applicant Contact Number: 2 Are there any current rent arrears owing on the main or joint applicant s tenancy? Yes No If yes, please answer the following questions and state which person they apply to: Amount of arrears owed? Main Applicant Joint Applicant Reason for the arrears? What arrangements have been made to pay these arrears? What payments have been made? Housing Application Form 9

10 Please use this page to help you calculate the Income & Expenditure details on page Housing Application Form

11 # Income and expenditure 1 Income You must provide proof of all income (e.g payslips, bank statements, award letters) and proof of any savings. Main Joint Payment Frequency Income Applicant Payment Applicant (per week, fortnightly, (amount) Frequency (amount) per month, 4 weekly or yearly) Wages (net after all deductions) Maternity Allowance Income Support/Job Seekers Allowance Working/Child Tax Credit State Retirement Pension Occupational/Private Pension Child Benefit/One Parent Payment Incapacity Benefit/Employment Support Allowance Maintenance Disability Benefit (e.g. DLA or PiP) Contributions (non dependants/lodgers) Housing Benefit Payment Interest Other Income (please specify) Total Income Total Income OFFICE USE ONLY App Ref:... Name:... Housing Application Form 11

12 Income and expenditure # If you do not currently have any outgoings, please estimate 2 Expenditure what your expenditure will be when you are re-housed. Main Joint Payment Frequency Expenditure - housing costs Applicant Payment Applicant (per week, fortnightly, and utilities (amount) Frequency (amount) per month, 4 weekly or yearly) Mortgage Payment Rent Rent or Mortgage Arrears Council Tax Life/Health Insurance House Contents/Building Insurance Electricity Electricity Arrears Gas Gas Arrears Water Rates Water Arrears Coal/Solid Fuel/Oil Home/Mobile Telephone Telephone Arrears Fines Maintenance Travel Expenses Catalogue Internet TV Licence TV Rental Pension/AVC payments not deducted by employer Other (please specify) Total Outgoings Total Outgoings 12 Housing Application Form

13 # Income and expenditure 3 Debts, fines and court orders Main Joint Payment Frequency Debts, fines and court orders Applicant Payment Applicant (per week, fortnightly, (amount) Frequency (amount) per month, 4 weekly or yearly) Credit Cards Hire Purchase Loan Payment (please state what loan(s) was for) County Court Judgement (CCJ) Court Fines Tax/National Insurance (non PAYE) Other (please specify) Total Outgoings Total Outgoings 4 Everyday expenditures Main Joint Payment Frequency Everyday expenditures Applicant Payment Applicant (per week, fortnightly, (amount) Frequency (amount) per month, 4 weekly or yearly) Food/Housekeeping Newspapers and Magazines Public Transport (work/school etc) Car Road Tax Fuel Car Insurance Car Service MOT, repairs, breakdown cover Childcare Child Pocket Money/School Trips School/Work Meals Pets food/insurance/vet bills Continued Housing Application Form 13

14 Income and expenditure # Everyday expenditures... continued Main Joint Payment Frequency Everyday expenditures Applicant Payment Applicant (per week, fortnightly, (amount) Frequency (amount) per month, 4 weekly or yearly) Cigarettes and Tobacco Clothes and Footwear Household Items repairs & replacements Health costs dentist, eye tests, prescription Other (please specify) Total Outgoings Total Outgoings 5 Other everyday expenditures Main Joint Payment Frequency Other everyday expenditures Applicant Payment Applicant (per week, fortnightly, (amount) Frequency (amount) per month, 4 weekly or yearly) Entertaining/Eating Out Holidays Savings Gardening Hobbies/Leisure Christmas/Birthday Presents Courses and Professional Fees Religious/Charitable Giving Other (please specify) Total Outgoings Total Outgoings 14 Housing Application Form

15 # Income and expenditure 6 Total income and expenditure Main Joint Payment Frequency Applicant Payment Applicant (per week, fortnightly, (amount) Frequency (amount) per month, 4 weekly or yearly) Total income Total housing costs/utilities Total debts/fines/court orders Total everyday expenditure Total other everyday expenditure Total Total: Expenditure: Expenditure: Amount left is calculated by: Total Income - Total Expenditure Amount Left: Amount Left: Housing Application Form 15

16 Notes - for office use only # 16 Housing Application Form

17 Property ownership and savings 1 Current property You must provide proof of any mortgage outstanding, any second charges against the property, any loan/credit card amounts, documentation of property repossession, sale or transfer. Do you, or anybody moving with you, currently own a property? Yes No If no, please go to question 2 A Please give the current valuation of the property B Is there an outstanding mortgage? please specify amount C Personal How many Details years are left on the mortgage? D Are there any other charges secured against the property? E.g. second mortgage. If yes, please specify Yes No E Do you have any outstanding loans/credit cards etc that will be cleared with any equity gained from a sale? Yes No If yes, please specify amounts F Is this property currently for sale? Yes No 2 Previous property A Have you or anybody moving with you, owned a property in the Yes No past 5 years? If no, please go to question D B What was the sale price? C Net total received from sale Please note net total is the total received after mortgage, solicitors fees and other relevant fees have been deducted. D Have you or anybody moving with you ever had a property repossessed? Yes No E Have you or anybody moving with you ever transferred a property Yes No into somebody else s name? If yes, please provide details below: Dates: Who transferred it: Their relationship to you: F Have you or anybody moving with you ever purchased a property from North East Derbyshire District Council or another local authority under the Right To Buy Scheme? If yes, please provide details Yes No Housing Application Form 17

18 Savings and Assets 1 We will require proof of any savings or any assets. Do you have any bank or building society Y N accounts? Do you have any Post Office accounts? Y N Do you have any Premium Bonds? Y N Do you have any National Savings Certificates? Y N Do you have any Stocks and Shares? Y N Do you have any savings such as Personal Equity Plans, ISA s, Unit Trusts Y N or Income Bonds? Do you have any money or property held in trust? Y N Yes or No Main Applicant Joint Applicant Amount Amount Do you have any other savings, investments Y N or cash? Total Total Previous addresses Please provide details of all the main and joint applicants previous addresses in the last five years. Please do not list your current home below. If you have named your partner/spouse as moving with you, please provide their previous address(es) in the joint applicant section. 1 You must provide proof of any previous address if you have lived there within the past six months. Council Tenant Owner Occupier Private Tenant Main Applicant CT OO PT Tenure Type Tied Tenant TT Lodger LO Housing Association Tenant HAT Shared Owner Tenure Date Date Reason for Address *please see moved moved leaving table above in out SO 18 Housing Application Form

19 Previous addresses Joint Applicant Tenure Date Date Reason for Address *please see moved moved leaving table above in out Have you, or anybody moving with you, ever been a council or housing association tenant? Yes No If yes, please provide the landlord s name and their address Landlord s name: Personal Details Do you, or anybody moving with you, have any rent arrears from any previous addresses? Yes No If yes, please provide details of address, landlord and the amount outstanding 1. Landlord s name: Amount outstanding: 2. Landlord s name: Amount outstanding: Have you, or anybody moving with you, ever been evicted from a property? Yes No If yes, please provide details Have any landlords ever taken legal action against you or anybody moving Yes No with you? If yes, please provide details including the landlord, property address and year of action Landlord s name: Year of action: Housing Application Form 19

20 Reasons for moving 1 Please tick all the following reasons that apply to why you wish to move. You may be required to provide supporting information before any priority can be awarded. At risk of losing current home Asked to leave by parents Asked to leave by family Asked to leave by friends Given notice by landlord Behind on mortgage payments Notice to leave Armed Forces Leaving Hospital/Care Risk of violence Relationship Breakdown Unsuitable Property Need 1 more bedroom Need 2+ more bedrooms Lacking essential facilities Sharing facilities Poor state of repair Need a smaller property Have adaptations I no longer need Medical Need adaptations that I do not currently have In property with stairs and have mobility problems Difficulty accessing bathing facilities Homeless Street homeless sleeping rough Living in temporary accommodation Unintentionally homeless TICK TICK BOX 3 BOX 3 Support Need to move to provide support Need to move to receive support In supported accommodation I no longer need Would benefit from supported accommodation (16-24yrs) Welfare/Social Current victim of domestic abuse Current victim of harassment/hate crime Current victim of anti social behaviour Financial Difficulties Isolated living in a village with no facilities/lack of public transport Other Want a council property Want a Housing Association property Are you interested in more information on the following Supported accommodation (under 25 s) Housing Association Properties Other affordable home ownership Shared Ownership Mutual Exchange/HomeSwapper Private Sector Tenancies Council Owned Properties 20 Housing Application Form

21 Reasons for moving 2 Where do you want to live? This section is to establish whether you have a connection to any area within North East Derbyshire. If you do have a connection, we can award extra waiting time for bids placed in that one area. If you do have a connection, you may still be allocated a property in another area dependant on where you place your bids. In all the below cases you must provide documentary proof of this connection (e.g. family member s utility bills that cover 5 years) A. Which area do you have a connection to? Please note, you can only have a connection to one area. B. If you have a connection, please tick the appropriate reason below: Have been living in the community for the last 12 months, or 3 out of the last 5 years Have a close family member (child, parent, sibling) who has lived in the community for at least the last 5 years Give or receive care/support from someone living in the community Need to live for education/training purposes Receive specialist medical treatment Need to move to or from supported housing which is near family Have employment reasons and have been working in the community/parish for at least the last 12 months People who need to move to the community, where failure to meet their need would cause hardship (to themselves or other family members) TICK BOX 3 Housing Application Form 21

22 Reasons for moving 3 Map of the District Marsh Lane Temple Normanton NORTH WINGFIELD C. Please list the top 5 areas you wish to live in, in order of preference: Housing Application Form

23 Reasons for moving 4 Please tick the property type(s) you require: House Bungalow Ground Floor Flat TICK TICK BOX 3 BOX 3 Upper Floor Flat Maisonette 5 6 How many bedrooms do you require? Please note, if you are claiming housing benefit you will only receive benefit for the number of bedrooms you require. Do you require any adaptations in your new property? Yes No If Yes, please state what type of adaptations Type of adaptations: 7 Would you consider a Housing Association property? Yes No Please note, by ticking yes you are consenting to us sharing your details with the housing association if you bid on one of their properties. Housing Application Form 23

24 General support 1 Nominated Person If you would like to give permission for someone to act on your behalf please give their details below. Please note, by providing these details you are giving us permission to discuss your re-housing with this person. You may withdraw this consent at any time by contacting us. Nominated person details Name: Phone Number(s): Agency (if applicable): Relationship to you: 2 Support Needs Please provide details of any agency currently working with you that is relevant for your housing application. Please provide any supporting letters from your support worker(s). Main Applicant GP Name: Name: Joint Applicant Tel. No: Tel. No: Health Visitor/Midwife Name: Name: Tel. No: Tel. No: Social Worker Name: Name: Tel. No: Tel. No: Continued 24 Housing Application Form

25 General support Support Needs...continued Main Applicant Joint Applicant Probation Officer Name: Name: Tel. No: Tel. No: Mental Health Team Name: Name: Tel. No: Tel. No: Other, please specify Name: Name: Tel. No: Tel. No: 3 Are you, or anyone moving with you, receiving or providing support from, or to, a family member? Yes No If yes, please request a Support Needs Form. 4 Are you or anyone being re-housed with you: A wheelchair user? If yes, please state if just indoors or outdoors or both Yes or No Y N Person affected A frail person who requires support? Y N A person with a learning difficulty? Y N A person with a visual impairment? Y N A deaf person? Y N A person with mental health problems? Y N A substance abuser e.g. drugs or alcohol? Y N A person who needs housing with a support worker? Y N Housing Application Form 25

26 Accessing Choice Move 1 Are you able to place bids yourself? Yes No If no, please explain why: 2 Do you require support from the Choice Move Team to place bids? Yes No Convictions 1 Please provide any court documents relevant to the conviction(s). PROOF Have you, or anybody moving with you, received an Anti Social Behaviour Order (ASBO)? Yes No If yes, please tell us who & why they received it: 2 Have you, or anybody moving with you, ever been convicted of a criminal offence? Yes No Have you, or anybody moving with you, ever been convicted of a criminal offence? Please only give details of convictions that are not spent, subject to the Rehabilitation of Offenders Act If yes, please tell us the information below. Who has the conviction: Nature of the offence: Sentence received, if any: Date convicted: 26 Housing Application Form

27 Relationships 1 Are you or the joint applicant, employed, or have ever been employed, by Rykneld Homes or North East Derbyshire District Council? Yes No If you answered yes, please give details 2 Are you or the joint applicant, a councillor of North East Derbyshire District Council or related to a councillor of NEDDC? Yes No If you answered yes, please give details 3 Are you or the joint applicant related to a Board Member or employee of Rykneld Homes? Yes No If you answered yes, please give details Data Protection We need your permission to use this information to enable us to make sure our services are delivered on an equal basis to all sections of the community. This may mean that we need to share this information with other parts of North East Derbyshire District Council and Rykneld Homes. Do you agree to the information you provide being held by the Council/Rykneld Homes to be used for these purposes? Yes No Housing Application Form 27

28 Application checklist Throughout the application you have been requested to provide evidence of your identity, address and circumstances. Your application will not be accepted and will be returned to you if you have not provided all of these documents or if the application is incomplete. Please complete the checklist below to ensure you have provided all necessary documentation: 1 Information about you One form of Identification (see page 2) Proof of National Insurance Number (see page 3) Proof of your current address (see page 3) Proof of indefinite leave to remain in the UK (see page 4) People moving with you One form of ID for anyone aged over 16 (see page 5) Proof of current address for anyone aged over 16 (see page 5) Proof of income for anyone aged over 16 (see page 5) The National Insurance Number for anyone aged over 16 (see page 5) Proof of bank statement for anyone aged over 16 (see page 5) The full birth certificate, child benefit or tax credit letter for every child under 16 (showing parent/child s name) (see page 5) Proof of access details (e.g. court papers) (see page 6) Proof of pregnancy (must show due date) (see page 6) Where you live now Tenancy Agreement (see page 7) Income and expenditure Proof of your earnings (e.g. payslip) (see page 10) Proof of all benefits you receive (see page 10) Proof of any bank statement you have (see page 10) Proof of any savings you have (see page 10) Property ownership and savings Proof of your outstanding mortgage (see page 11) Proof of any charges outstanding on properties (see page 11) Proof of any loans/credit card amounts (see page 12) Proof of property sale & amount received (see page 15) Proof of any property repossession (see page 15) Proof of any transfer of property (see page 15) Main Applicant Joint Applicant 28 Housing Application Form

29 Application checklist Previous Addresses Proof of previous address if moved in the last six months (see page 16) Reasons for moving Proof of your community connection (see page 19) General support Proof of supporting letters from your support worker(s) (see page 22) Convictions Proof of any criminal conviction(s) (see page 24) Main Applicant Joint Applicant 2 Additional information Would you need to complete any of the following forms? Please contact the Choice Move Team on , go to our website or go into one of our housing offices for further information or to get a form: Medical Needs Assessment Form Domestic Violence Statement Support Needs Form Main Applicant Joint Applicant 3 Please tick the following to ensure that you, and the joint applicant, have completed and understood the following which relate to your application and the re-housing process. You have answered all questions on the form You have provided all documentation requested If you are a NEDDC tenant have you been on HomeSwapper for six months (if applicable) TICK TICK BOX 3 BOX 3 You will be required to bid on suitable available properties each week You must ensure your details are kept up to date so your application is correct You are aware you may be asked to view at short notice and will be required to pay your first weeks rent at sign up Housing Application Form 29

30 Declaration We will treat all the information you provide in confidence and in accordance with the Data Protection Act We will use it for the purpose of processing your application. We will need to share it with other departments or organisations to get further information for your application. These include, but are not restricted to, Housing Benefit, Rykneld Homes Housing Offices, Housing Associations, Council Tax, The Department for Work and Pensions, Experian or other credit reference agencies, Probation Service, Police, Social Services and other local councils. We may occasionally need to pass your details to other organisations. These include, but are not restricted to, Housing Options Team, P3 idecide, Housing Associations. We may also use it to contact you from time to time to review your information and our service to you. Declaration you are responsible for the information on this form and must sign the declaration even if someone else has filled in this form for you. If you have a joint applicant, they must sign the declaration as well. Please read it carefully before you sign and date it. I give Rykneld Homes/partner landlords permission to contact my present and/or former landlords, any of the agencies listed and any other relevant agencies. I authorise them to disclose any information held by them for the purpose of dealing with my application for housing. I understand that any information given to Rykneld Homes/partner landlords will be used by them in relation to my application for housing. I also authorise Rykneld Homes to undertake a credit reference check if considered necessary. I understand that any information I have given may be shared with other parts of North East Derbyshire District Council and other organisations responsible for managing public money for reasons of preventing and detecting fraud. I confirm that the details I have given in this application are true and correct. I understand that if I have knowingly or recklessly given any false information or have not given information which would affect my application, Rykneld Homes will not process my application form, may take legal action against me, and Rykneld Homes/partner landlords may, by law, end my tenancy. I also agree to inform Rykneld Homes of any change in my personal or housing circumstances so that the information held on my application is accurate and true. I understand that if I have knowingly or recklessly not given information on my current circumstances, Rykneld Homes/partner landlords may withdraw an offer of housing, cancel my housing application and may take legal action against me. Main Applicant Signature:... Date:... Joint Applicant Signature:... Date:... Has anyone other than the main or joint applicant filled in this form? Yes No Name of person who filled in the form Signature Phone Number Relationship to applicant Agency (if applicable) Date 30 Housing Application Form

31 # Equal Opportunities Monitoring Form MAIN APPLICANT TO COMPLETE At North East Derbyshire District Council and Rykneld Homes we take equality seriously and are committed to providing fair services to everyone. The Council and Rykneld Homes will not put up with discrimination for reasons of race, gender, disability, age, religion or sexual orientation. You do not have to fill in this form or answer any question you do not feel comfortable with, however, these statistics will help us to carry out our Equality Policy and monitor procedures. Ethnic Background WHITE MIXED CHINESE British White and Asian Chinese Irish Polish Any other white background White and Black African White and Black Caribbean Any other mixed background BLACK OR BLACK BRITISH ASIAN OR ASIAN BRITISH OTHER Black African Bangladeshi Traveller Black Caribbean Indian Gypsy Any other black background Any other Asian background Any other ethnic Gender Date of Birth Male Female What is your date of birth DD/MM/YYYY background Disability The definition of Disability in the Disability Discrimination Act 1995 is: A physical or mental impairment which has a substantial and long term adverse affect on a person s ability to carry out normal day to day activities. Do you consider yourself to be disabled? No Yes Are you already a tenant of NEDDC? No Yes You do not have to answer the following questions, however, if you do this information will be held in the strictest confidence. Religion Sexuality Buddhist Muslim Heterosexual Christian Sikh Gay Hindu Any other religion Lesbian Jewish No religion Bisexual Thank you for your co-operation Housing Application Form 31

32 No English? No problem & (ENGLISH) We care. We want all of our customers to be able to access all of our services. To talk to someone in English, ring this number. You will not be charged for the TALKBACK service. & (CANTONESE) & (MANDARIN) & (ITALIAN) & (URDU) If you require this publication in large print, braille or on audio CD please call us on & (POLISH) & (PUNJABI) & (OTHER LANGUAGES) Rykneld Homes Limited is a company limited by guarantee, controlled by North East Derbyshire District Council and registered in England and Wales. Registered number is Registered Office is: Pioneer House, Mill Lane, Wingerworth, Chesterfield, Derbyshire S42 6NG. Registered Provider number Designed by North East Derbyshire District Council (8075 January 2017)