HOUSING APPLICATION FORM (Online Application)

FOR OFFICE USE ONLY HOUSING APPLICATION FORM (Online Application) Date Sent..... Date Received:... Application Type:... Bed Size: Banding:.. Ref TO ENABLE US TO ASSESS YOUR HOUSING NEEDS, PLEASE ENSURE YOU COMPLETE ALL SECTIONS ON THIS FORM. IF YOU DO NOT COMPLETE ALL SECTIONS, WE WILL BE UNABLE TO PROCESS YOUR APPLICATION AND THE FORM WILL BE RETURNED TO YOU. PLEASE COMPLETE THIS FORM USING BLACK INK AND CAPITAL LETTERS MAIN APPLICANT Title: Mr/Mrs/Miss/Ms Surname:. Previous Name(s): First Names:.. Sex: M/F.. Marital Status:.. Date of Birth: Age:... Address:.. Postcode: Date you began living at this address:. Tel: Home: Work:. Mobile:. Email address: National Insurance No:. Are you an asylum seeker? YES NO If YES, do you have indefinite leave to stay? YES NO Proof will be required (e.g. Copy of leave to remain card, Home Office letter, Certificate of naturalisation etc ) JOINT APPLICANT Title: Mr/Mrs/Miss/Ms Surname:. Previous Name(s): First Names:.. Sex: M/F.. Marital Status:.. Date of Birth: Age:... Address:.. Postcode: Date you began living at this address:. Tel: Home: Work:. Mobile:. Email address: National Insurance No:. Are you an asylum seeker? YES NO If YES, do you have indefinite leave to stay? YES NO Proof will be required (e.g. Copy of leave to remain card, Home Office letter, Certificate of naturalisation etc ) Tell us where to contact you if you do not wish us to contact you at the above address Address:. Postcode.. bchs is part of the Accord Group 1

bchs is part of the Accord Group 2

1. WHAT TYPE OF ACCOMMODATION DO YOU NEED? Bedsit Flat House Bungalow How many bedrooms do you need? TYPES OF PROPERTY YOU WOULD NOT ACCEPT: Please list below any types of property (e.g. flats, bedsits or above 1 st floor) that you would not be interested in. PREFERRED AREA TO MOVE TO: Please list below in order of preference by marking 1 next to your first choice, then 2, 3 and so on. SMALL HEATH BORDESLEY GREEN HANDSWORTH SALTLEY MOSELEY (1 bedroom only) BALSALL HEATH LOZELLS YARDLEY (3 bedroom only) PLEASE GIVE REASON(S) FOR YOUR FIRST CHOICE: (For example: Closer to work, Closer to Family, Closer to Children s School/Nursery etc ) DETAILS OF ANY RELATIVES IN THE AREA YOU MARKED AS YOUR FIRST CHOICE: NAME ADDRESS RELATIONSHIP TO YOU ARE YOU REGISTERED FOR RE-HOUSING WITH BIRMINGHAM CITY COUNCIL? Enter YES or NO bchs is part of the Accord Group 3

2. PLEASE TELL US ABOUT WHERE YOU LIVE NOW Are you or the joint applicant: YOU JOINT APPLICANT Living in shared accommodation? Living in Bed & Breakfast accommodation? Living in a hostel? In prison? Living with family or friends? An Owner Occupier (homeowner)? YES NO YES NO If YES above, have you sold or are you selling your home? A Housing Association tenant? YES NO YES NO A Council tenant? A tenant of a Private landlord? Other? Please give details Name and Address of Current landlord (If applicable) Do you or the joint applicant currently live in a: (please complete the boxes) YOU JOINT APPLICANT House No of Bedrooms House No of Bedrooms Bungalow No of Bedrooms Bungalow No of Bedrooms Bedsit Floor level Bedsit Floor level Flat No of floor Bedrooms level Other No of floor Bedrooms level Flat No of floor Bedrooms level Other No of floor Bedrooms level bchs is part of the Accord Group 4

Do you or the joint applicant have any arrears at this address? YES NO If YES, please specify (i.e. mortgage, rent, service charge etc) and how much outstanding. 3. PLEASE TELL US ABOUT YOUR OCCUPATION AND INCOME OCCUPATION: tick relevant box for yourself & joint applicant (if applicable) YOU JOINT APPLICANT EMPLOYED SELF EMPLOYED UNEMPLOYED STUDENT HOUSEWIFE/HUSBAND RETIRED OTHER If OTHER please provide details:... EMPLOYMENT DETAILS : if you or the joint applicant are employed please complete below, if applicable YOU Name & Address of your employer: Tel No: Can you be contacted at work: YES / NO JOINT APPLICANT Name & Address of your employer: Tel No: Can you be contacted at work: YES / NO MAIN APPLICANT OR JOINT APPLICANTS INCOME: please complete relevant section by ticking box YOU JOINT APPLICANT up to 15,000 up to 15,000 15,000-25,000 15,000-25,000 30,000-35,000 30,000-35,000 40,000 and over 40,000 and over bchs is part of the Accord Group 5

DO EITHER OF YOU OWN ANY PROPERTY? enter YES or No. YOU MUST ANSWER THIS QUESTION If YES please give details... 4. CURRENT SLEEPING ARRANGEMENTS AT YOUR CURRENT ADDRESS: enter details requested for each person living at your current address FOR EXAMPLE BEDROOM 1 JOHN JOAN SMITH SMITH 01/01/1990 M F HUSBAND & WIFE BEDROOM 2 JOE BLOGGS 25/12/2005 M SON BED ROOM FIRST NAME SURNAME DATE OF BIRTH SEX (M/F) RELATIONSHIP TO YOU 1 2 3 4 bchs is part of the Accord Group 6

PROVIDE DETAILS OF ALL THE PEOPLE WHO WILL BE MOVING WITH YOU. IMPORTANT - You must answer this question. FIRST NAME SURNAME SEX (M/F) DATE OF BIRTH ETHNIC ORIGIN RELATIONSHIP TO YOU WORKING FULL OR PART TIME Are you or any of the above named pregnant? If so, when is the expected due date?... (IF YES PLEASE SEND IN PROOF OF PREGNANCY FROM 26 WEEK GESTATION) bchs is part of the Accord Group 7

FAMILY SEPARATED BECAUSE OF HOUSING CONDITIONS : if members of your family are not living with you because of your housing conditions, give provide details below : 5. YOUR CURRENT LIVING CONDITIONS AMENITY SOLE USE OF SHARED DO NOT HAVE INSIDE TOILET HOT WATER BATHROOM COOKING GARDEN CONDITION OF YOUR PROPERTY: please tick below the row that best describes your current property and give details where relevant. Please enclose copies of any supporting documents (e.g. Photos or Environmental health letters) to your application. We cannot consider the condition of your current accommodation as a Housing need without supporting photographic evidence CONDITION TICK DETAILS An environmental health notice has been served confirming property is unfit and/or a danger to health and safety General lack of repair likely to endanger health Poor state of repair and condition Property is in good condition Please note, an inspection of your current accommodation may be carried out to verify this, bchs is part of the Accord Group 8

ARE YOU REGISTERED DISABLED? NO YES (Please provide proof) DO YOU OR ANY OF YOUR FAMILY HAVE ANY MEDICAL CONDITIONS WHICH MAY BE AFFECTED BY YOUR CURRENT HOUSING? We will require written confirmation from your doctor, medical social worker, occupational therapist etc, which may incur a fee. (We regret we cannot reimburse you for this confirmation). NAME OF PERSON MEDICAL CONDITION (and how your current accommodation is affecting this e.g. unable to use stairs) SUPPORTING LETTER ENCLOSED (doctor/health worker letter) bchs is part of the Accord Group 9

6. PLEASE TELL US ABOUT YOUR PREVIOUS HOUSING MAIN APPLICANT Have you previously applied to bchs for rehousing? YES NO If yes, when did you apply?... Please give details of all addresses where you have lived over the last 5 years. (Please use the space on the Additional Application Information Sheet, if necessary) ADDRESS LANDLORD S NAME AND ADDRESS MAIN APPLICANT TENURE TYPE* FROM TO REASONS FOR LEAVING ARREARS** * i.e., lodger, owner, tenant etc ** please enter amount of arrears outstanding, if applicable Were you forced to leave your home as a result of a Court Order or other official notice? If so, please provide details. bchs is part of the Accord Group 10

PLEASE TELL US ABOUT YOUR PREVIOUS HOUSING JOINT APPLICANT (if applicable) Have you previously applied to bchs for rehousing? YES NO If yes, when did you apply?... Please give details of all addresses where you have lived over the last 5 years. (Please use the space on the Additional Application Information Sheet, if necessary) ADDRESS LANDLORD S NAME AND ADDRESS JOINT APPLICANT TENURE TYPE* FROM TO REASONS FOR LEAVING ARREARS** * i.e., lodger, owner, tenant etc ** please enter amount of arrears outstanding, if applicable Were you forced to leave your home as a result of a Court Order or other official notice? If so, please provide details. bchs is part of the Accord Group 11

7. PLEASE TELL US ABOUT YOUR REASONS FOR WANTING TO MOVE Have you or the joint applicant been given a date to leave your current home? YES NO DATE: Are you or the joint applicant experiencing a relationship breakdown? YES NO Are you or any member of your immediate family suffering any from YES NO of harassment, violence or domestic violence? If YES TO ANY OF THESE, please give details (including supporting documentation) PLEASE TELL US IN AS MUCH DETAIL WHY YOU WISH TO MOVE. Continue on a separate sheet if necessary. You MUST complete this section.... bchs is part of the Accord Group 12

PETS: Please give details of any pets you have; this will enable us to assess your suitability for particular properties; e.g. dogs are not allowed in some properties. If you do not have any pets, please enter None. Details:. 8. CONFLICT AND DECLARATION OF INTEREST Connections to bchs, Housing Co-operatives and the Accord Group employees and Committee Members Are you or is anyone else included in this application: an employee or Board Member of the Accord Group? Yes / No related to, or associated with, someone working for the Accord Group? Yes / No related to or associated with, someone on the Committee of a Birmingham Housing Co-operative Yes / No If yes to any of the above, please provide the following information: The name of the person: Your relationship (for example father, partner):.. The position they hold:... 9. GENERAL PLEASE READ THE ENCLOSED GUIDE TO HOUSING WITH BCHS OR A HOUSING CO-OPERATIVE AND FLOWCHART BEFORE COMPLETING THIS SECTION. a. Are you prepared to accept the responsibility of becoming a Co-operative tenant? YES NO (PLEASE ANSWER THIS QUESTION) b. Having read the Guide to Housing with Bchs or a Housing Co-operative sent with this application, please explain why you wish to become a member of a Co-operative? bchs is part of the Accord Group 13

Continuation of question b:. c. What do you feel you could contribute to the efficient running of a Co-operative? (e.g. type of skills you could offer, voluntary experience etc )............................ IMPORTANT Please note, if you do not answer question 9 (a, b & c) we will not be able to consider you for a Housing Co-operative property. bchs is part of the Accord Group 14

10. DECLARATION a) To the best of my knowledge, the answers given on this form are true. b) I understand that completion of this form does not necessarily mean I will be offered housing. c) I understand that I must tell bchs if there are changes in my circumstances. I understand that if accommodation is offered on the basis of false information, bchs [or housing co-operative] may decide to end the tenancy and will take immediate action to regain possession of my home. d) I also note that, with the exception of Assistance Dogs, the keeping of pets will only be allowed at the discretion of bchs or housing co-operative. e) I agree to bchs making necessary enquiries concerning this application including tenancy checks with current or previous landlords and any other agency and authorise those agencies to give information to bchs. f) I understand that bchs will use the information on this form for the following:- to assess my housing needs, statistical purposes and to provide details upon request to local authorities, other Government Public bodies, including those reporting to the Home Office. g) I understand that any aggression shown towards bchs staff may result in my application being refused. h) I understand that under any information provided may be used for purposes other than re-housing (Data Protection Act) i) Unfortunately, sometimes tenants leave our properties (or co-op properties) without paying their bills. Our policy is to recover any money owed to us. We want you to give us your consent to ask other people or Organisations to give details of how to contact you and to authorise them to disclose this information to us. We will only use this consent if money is owned to us and we do not have your contact details. Where there is a debt owed in connection with a property rent by bchs or housing co-operative, and they are unable to contact me, I authorise bchs to ask ANY person or organisation that is likely to hold my contact information to disclose that information to them. I also consent to any person or organisation approached by bchs to disclose my contact information to them. Some of the organisation that we may disclose information to or request information from could be;- Local authorities Department of Work and Pensions Internal Council Departmetns Bank/Building Societies DVLC/DVLA Utilities companies BT Other Housing Associations Private Landlords I have read and understand these details: Signature of applicant: Date: Print Name: I have read and understand these details: Signature of second applicant: Date: Print Name: bchs is part of the Accord Group 15

EQUAL OPPORTUNITY FOR ALL It is against the law to discriminate against anyone because of their sex, colour, race or religious belief. To help us make sure that this policy is carried out, and for no other reason, the following information is requested. Please tick answer for yourself and one for your spouse / partner. ETHNIC ORIGIN You Your Spouse / Partner WHITE 1. British 2. Irish 3. Other White Please specify COMBINATION OF GROUPS 4. White/Black British 5. White/Black African 6. White/Asian 7. Other Combination Please Specify. ASIAN OR ASIAN BRITISH 8. Indian 9. Pakistani 10. Bangladeshi 11. Other Asian Please Specify. BLACK OR BLACK BRITISH 12. Caribbean 13. African 14. Somalian 15. Other Black Please Specify. CHINESE OR OTHER ETHNIC GROUP 16. Chinese 17. Other Ethnic Group Please Specify. 18. Refuse to answer Other Information (Please Specify) If you do not answer these questions, it will not harm your application for housing (please turnover) bchs is part of the Accord Group 16

FIRST LANGUAGE Joint Joint You Applicant You Applicant ARABIC BENGALI ENGLISH GUJARATI OTHER HINDI PUNJABI URDU BRITISH SIGN LANGUAGE Please specify You. Joint Applicant..... Please state your religion: Main Applicant: Joint Applicant: Make sure you have completed all relevant questions and return the form within 21 days, To: BCHS at 106 Alcester Road, Moseley Birmingham, B13 8EF Please note that it is important that you tell us about any future change in your circumstances as this may affect your housing application. Contact BCHS as soon as possible to tell us what those changes are. bchs is part of the Accord Group. We advise applicant(s) that the data held by Accord Group in respect of your application form will be used for cross-system and cross-body comparison for the prevention and detection of fraud. bchs is part of the Accord Group 17

Social Housing Landlord Reference Consent Form By signing this form you are consenting to your current or previous landlord/s providing the information as set out below I/We give consent for the information below to be shared with Bchs as part of the housing application. Main Applicant print name:. DOB... Joint Applicant print name:. DOB.. Main Applicant signature: Date: Joint Applicant signature: Date:. Below are the questions we will be asking your current and previous landlord/s. Please read them carefully. 1. How long were/have they been a tenant? 2. How was the rent paid? 3. Is there ANY debt owed to you by the tenant? If Yes: Has there been any notices served or court action taken? How much is owed? What is the debt for? Is there an agreement in place to clear the debt? If there is an agreement in place how long has it been in place? If there is an agreement in place, have payments been consistent? 4. If there is NO agreement in place: Have you attempted to collect the debt? If the tenant is a former tenant of yours, did they know they had debt when they left? 5. Does/ did the tenant communicate and engage with you? Are they in when you arrange appointments? Do/Did they allow repairs and gas servicing to be completed? 6. Is there a record of nuisance or Anti-Social Behaviour or any other breaches of tenancy in relation to family members or visitors? 7. Have there been any issues with the property condition? (where known) 8. Has the tenant caused any damage to your property? (where known) 9. Do you have any photos or video recordings of any tenant damage to the property or its condition? 10. Are you aware if the tenant (or anyone that lives with them) has any support needs or has any support from other agencies? 11. Do you feel the tenant is able to maintain a tenancy without support? 12. Do you believe that this person is safe to be visited alone? 1