MUTUAL EXCHANGE APPLICATION - INFORMATION FOR TENANTS 1. All applications for Mutual Exchange will be considered but not all will be allowed. For example an exchange where the property would be much too big or much too small for you, or if the property is specially adapted for the elderly, or disabled, or if the area has an age restriction would not be permitted. This is not a complete list of the reasons for refusal but you will be notified of the reasons following consideration of your application. If you wish to discuss in what other circumstances an exchange will be refused please contact us. 2. Applications to exchange must be made by the tenant as only tenants may exchange. 3. No exchange may take place without getting written permission first from A2Dominion Group or whichever Group Company is your landlord and any other Housing Association or Council involved. 4. Your application to exchange may be refused if you have broken your tenancy conditions. If you have rent arrears and/or any other sundry debts these must be cleared before the exchange can take place. Please also be advised that you are not permitted to have one or more additional bedrooms above your housing need. If we deem you to have this, your application will be refused. 5. You must make sure you want the property in its present condition. Repairs needed, as a result of unauthorised improvements, alterations or damage or neglect by the present tenant, will not be carried out by your new landlord. 6. If repairs are necessary in your property as a result of your unauthorised improvements, alterations or damage or neglect, then you are in breach of your tenancy and will either have to rectify the breaches or you will have to pay for any necessary work before you exchange. You must remember that fixtures and fittings, such as kitchen units, electric dimmer switches, shower units and gas fires, are part of the property and must be left behind when you leave even if you installed them yourself. 7. You must ensure that you have viewed the property you wish to exchange into thoroughly before exchanging as A2Dominion will only carry out a visual inspection of the property, and will not be accountable or responsible for faults/issues you may find after moving. 8. If you have a storage shed, you must remember to hand over the keys. Failure to do so will result in a charge being made to you for the lock to be changed. You must also remember to dispose of any unwanted effects or rubbish and not leave them in the property. 9. You must ensure that all rubbish is cleared from the property, any garden connected to the property and/or communal areas before you move. 10. A2Dominion have restrictions on the type of pets you may keep. Please check with us. 11. You are not permitted to give or accept money if you carry out a mutual exchange. If you have either given or accepted any money in order to exchange, A2Dominion may take legal action which could result in you losing your home. 12. Please note that A2Dominion has 42 days to make a decision on whether your mutual exchange can go ahead, as laid out in the Housing Act. Signed by the Current Tenant(s) Tenant Signature.. Date 1
Tenant Signature Date ( NB Where a joint tenancy is held both signatures are required ) MUTUAL EXCHANGE APPLICATION FORM THIS PART OF THE FORM NEEDS TO BE COMPLETED BY THE PROPOSED OUTGOING TENANT/S Name: Current Address: Daytime Telephone No.: Work Telephone No.: Mobile Telephone No.: FAMILY DETAILS: (Please list everyone in your household who would be moving in with you, including yourself). Name Date of Birth Relationship National Insurance No. Property Details Type of property you currently occupy Number of bedrooms Number & type of pets 2
Do you have your own private garden Yes/No If a flat, what floor level is it on? Ground 1 st 2 nd 3 rd Other Is your home adapted for people with disabilities? Yes / No Is your home designed for elderly people only? Yes / No Reason for Moving? Is this part of a 3 way exchange? Details of 3 rd Party Yes / No Name Address Landlord Details THIS PART OF THE FORM NEEDS TO BE COMPLETED BY THE PROPOSED INCOMING TENANT. DETAILS OF PERSON WISHING TO EXCHANGE: Name: Address: Daytime Telephone No.: Work Telephone No.: Mobile Telephone No.: FAMILY DETAILS: (Please list everyone in your household who would be moving in with you, including yourself). Name Date of Birth Relationship National Insurance No. Property Details 3
Type of property you currently occupy Number of bedrooms Number & type of pets Do you have your own private garden? Yes / No If a flat, what floor level is it on? Ground 1 st 2 nd 3 rd Other Is your home adapted for people with disabilities? Yes / No Is your home designed for elderly people only? Yes / No Are you in receipt of Universal Credit? Yes / No Please state date Universal Credit is received each month Name and Address of current Landlord Reason for moving PERSONAL DETAILS Applicant Joint Applicant Title Mr Mrs Ms Miss Mr Mrs Ms Miss Gender/Sex Male Female Male Female Marital Status Civil Partnership Divorced Married Other Separated Single First Name (s) Surname Date of Birth National Insurance No Civil Partnership Divorced Married Other Separated Single 1. Is anyone on your application pregnant? Yes No Name: Expected due date: / / 2. Do you currently have any rent arrears? Yes No 4
How much do you owe? Do you have a repayment plan in place? Yes No Are you keeping to this arrangement? Yes No How much do you pay? weekly/fortnightly/monthly 3. How many vehicles do you own? 0/1/2/3/4/5 INCOME AND SAVINGS 4. Are you or anyone on your application employed or self employed? Yes No Name Occupation Employers name and address Gross salary per week 5. Are you or anyone on your application in receipt of state benefits (including Housing Benefit) or have a grant or a student loan? Yes No Name Type of benefit (i.e. Income support, JSA) Weekly amount Date of initial claim Housing Benefit Yes/No / / / / 5
/ / / / / / 6. Are you or anyone on your application retired? Yes No Name Type of benefit (i.e. state/private pension Weekly amount Date of initial claim / / / / 7. Do you or anyone on your application have any savings or investments? Yes No Name Type of Savings/Investments Amount MEDICAL 8. If you or anyone on your application has a medical condition, please provide details below. Name Name & Address of Doctor Medical Condition 6
- 9. Do you have any specific floor level requirements? Yes No EQUAL OPPORTUNITIES A2Dominion is committed to providing equal treatment and opportunity in access to housing and will not discriminate against or treat less favourably any housing applicants on the grounds of race, colour, ethnic or cultural origin, nationality, religious beliefs, sexual orientation, gender, age, marital or family status, mental or physical disability or physical appearance. The help ensure that this aim is fairly carried out, we monitor applications and ask for details such as your ethnic origin and religion. The section on disability will help us in property design and adaptations. Any information you give us is strictly confidential and will only be used to provide us with statistics to enable us to monitor our Equal Opportunities policy. The answers you give will not affect your application for housing. 13. Which languages are spoken within your household? Albanian Arabic Bengali Mandarin English Farsi French Guajarati Hindi Kurdish Polish Portuguese Punjabi Somali Spanish Tamil Turkish Urdu Other Please State What is your first language? 14. How do you describe your ethnic origin? (please tick one) White Applicant Joint Applicant White British White Irish White Other Mixed Mixed White & Black Caribbean 7
Mixed White & Black African Mixed White & Asian Mixed Other Asian or Asian British Asian or Asian British Indian Asian or Asian British Pakistani Asian or Asian British Bangladeshi Asian or Asian British Other Black or Black British Black or Black British Caribbean Black or Black British African Black or Black British Other Chinese or Other Ethnic Group Chinese Other (please state) Prefer not to say 12. How do you describe your sexuality? 13. Do you have a faith or (please tick one) religion (please tick one) Lesbian Gay Heterosexual Bisexual Prefer not to say Other (please state) None Buddhist Christian Hindu Jewish Muslim Sikh Prefer not to say Other (please state) 14. Please Tick as appropriate. DISABILITIES DISABILITY Defined as a physical or mental impairment which has a substantial and long term affect on his/her ability to carry out normal day to day activates as described by Section 1 of the Disability Discrimination Act 1995. a) Does anyone in your household have a disability? Yes No b) Type of disability Yourself Your Partner Dependants Visual Hearing Mobility 8
Other c) Does anyone in your household have a mobility issue? If yes then specify from the list below. Mobility Group 1 Suitable for wheelchair user indoors and outdoors Mobility Group 2 Suitable for people who cannot manage steps or stairs and may use a wheelchair some of the day Yes No Mobility Group 3 Suitable for people only able to manage 1 or 2 steps or stairs d) Does anyone in your household require any aids & adaptations in your new home? Yes No Does anyone in your household have an Occupational Therapist? Yes No If YES, please provide name of Occupational Therapist e) If anyone in your household has any sight/visual difficulties, please provide details below. f) If anyone in your household has any hearing difficulties, please provide details below g) If anyone in your household has any other difficulties that could affect their ability to understand forms or rules, please provide details below. SUPPORT NEEDS Does anyone in your household have any support needs? Yes No If YES, please select from the options below. Drug/Alcohol Yes No Mental Health Yes No Physical Disability Yes No Other, please provide details below. Yes No 9
Does anyone in your household currently have a support worker or any other agency involvement? If YES, please provide details below Yes No 15. Do you require any help with claiming benefits or debt management? Yes No If you have answered yes A2Dominion can provide help with debt management advice, making offers to creditors and help residents claim all the benefits they are entitled to which includes Community Care Grants. Would you like us to refer you to our Tenancy Sustainment Officer or Welfare Benefits Advisor? Yes No 16. Have you ever been a tenant of any of the following? Yes No Please Tick: A2Dominion Kelsey Housing Association Cherwell Family Housing Association A2 Housing Spelthorne Housing Association Acton Housing Association Cherwell Housing Trust Airways Housing Association Apex Housing Group If YES, please provide the address below. 17. Have you ever been evicted from a property or had a notice served for? Rent Arrears Yes No ASB (Anti-Social Behaviour) Yes No Other, please specify Yes No 18. Has anyone on your application been convicted or cautioned of an offence under the Sex Offenders Act 1997? Yes No If YES, please provide name and date of conviction below. 10
19. Has any member of your household been convicted or currently on probation or have been in the last 5 years? Yes No If YES, please provide the details below. Name Conviction Sentence Probation Officer Probation Contact Details 20. Have you ever been subject to? An Injunction? Yes No A Demotion of tenancy? Yes No An Acceptable Behaviour Contract (ABC) Yes No An Anti-Social Behaviour Order (ASBO) Yes No CONNECTION TO A2DOMINION GROUP 21. Do you have any connection to A2Dominion Group? Yes No Employees of the Group Yes No Committee Members Yes No Any close relative to Staff or Committee Members Yes No Principal Proprietor of any business with whom the Group is trading Yes No IMMIGRATION STATUS 22. Is each member of the household a citizen of the UK or a citizen of a country in the European Economic Area? Yes No 23. If you have answered NO to the above question does the relevant person(s) have Indefinite Leave to Remain? Yes No You will be required to provide proof of Indefinite Leave to Remain or on restrictions on Indefinite Leave to Remain. 11
24. Please tick one of the boxes below if you or any member of your household is from any of the following countries. Country Yourself Joint Applicant Other Member Slovenia Slovakia Hungary Lithuania Latvia Poland Czech Republic Estonia If you are from one of the above countries please provide proof that you have Permanent Right to Reside in the United Kingdom. NEXT OF KIN DETAILS Please provide us with details of your next of Kin Name of next of kin Address of next of kin Relationship to you Home telephone number Mobile number Work telephone number DECLARATION 12
I/We have inspected property at address: and if the exchange is agreed by A2Dominion I/we will accept the property in its existing condition, including any alterations made by the present tenant or any former tenants. I/We recognise and accept that any alterations made by the present or former tenants to the property will become my responsibility to maintain and repair and NOT the responsibility of A2Dominion. (This does not affect any repair works that are the responsibility of A2Dominion). I/ We understand that we must not exchange until after a formal offer of assignment has been sent to me/us By signing and returning this document, you expressly consent to A2Dominion using and keeping any personal information about you contained in this form and sharing such information with other relevant organisations where we deem it necessary or appropriate for us to perform our functions as a registered social landlord. This includes any sensitive personal information you have provided, such as details relating to your health, ethnic origin or criminal record. Such using, keeping and sharing of information will be carried out in accordance with the Data Protection Act 1998 and Crime & Disorder Act 1998. This needs to be signed by the proposed incoming tenant. TENANTS SIGNATURE(S) Tenant 1 Name. Signature... Tenant 2 Name. Signature. ( NB. Where a Joint Tenancy is to be held both signatures will be required ) Date. PLEASE RETURN COMPLETED FORM TO YOUR LOCAL OFFICE BELOW: 13
BROMLEY OFFICE A2Dominion Northside House 69 Tweedy Road Bromley BR1 3WA BR: 1, 2, 3, 4, 5, 6, 7 BN: 21 / CR: 2, 8 DA: 6, 8, 14, 15 E: 2, 8, 13, 14, 15 RM: 1 SM: 1, 4, 5, 6 SE: 9, 13, 18, 19, 20, 23, 25, 26 EALING A2Dominion 113 Uxbridge Road Ealing W5 5TL SPELTHORNE / STAINES A2Dominion Spelthorne House Thames Street Staines-upon-Thames TW18 4TA HA: 0, 1, 2, 3, 4, 5, 6, 7, 8, 9 NW: 1, 2, 3, 5, 6, 8, 9, 10 SW: 5, 6, 10, 11, 12, 15, 16, 18, 19, 20 SW1: P, V, W, X TW: 3, 4, 5, 7, 8,9, 11, 12, 13, 14 UB: 1, 2, 3,4, 5, 6, 7, 8, 9, 10 W1: F, T, U W: 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14 GU: 30, 47 EN: 1, 3 WD: 19 RM: 13 KT: 1, 2, 4, 8 TW: 1, 2, 15, 16, 17, 18, 19, 20 SL: 1, 2, 3, 4, 5, 6 KT: 6, 10, 11, 12, 13, 15, 16 GU: 1, 2, 8, 12, 14, 15, 16, 19, 21, 26, 51 SN: 25 OXFORD A2Dominion Godstow Court 5 West Way Oxford OX2 0GE RG: 1, 2, 3, 4, 5, 6, 7, 12, 14, 17, 18, 19, 20, 21, 24, 26, 30, 31 RH: 1, 4, 5, 6 HP: 7 OX: 1, 2, 3, 4, 9, 10, 11, 14, 15, 16, 18, 26 SN: 3, 4 WINCHESTER A2Dominion 33 Staple Gardens Winchester SO23 8SR SP: 1, 2, 3, 4, 5, 6 SO: 5, 14, 15, 21, 22, 23, 24, 30, 32, 42, 43, 50, 53 GU: 33, 34 PO: 5, 9, 14, 17, 18, 19, 20 14