Housing Application Form

Please complete the application as fully as possible. It is important to give as many details as you can since your application will be considered initially on the information you provide. Any information you give will be treated in strict confidence by the Association. However, you should be aware that the Association is registered under the Data Protection Act 1984. By law all information held on computer has to be disclosed if requested to bodies which have good reason for asking for this information - for example, the Inland Revenue or the Police. You also have a right to check what information the Association has about your application on computer, and have this amended if it is wrong. Should you require any assistance in completing the application form, please do not hesitate to contact the Association on 01686 627476.

YOUR DETAILS			YOUR AREAS OF INTEREST
Name			1st Choice
Address line 1			2nd Choice
Address line 2			3rd Choice
Town			4th Choice
County
Postcode
Home Phone
Other Phone
Email Address

1. YOUR HOUSEHOLD
a) Please give details of everyone who will be living with you in the accommodation for which you are applying, including yourself.
Name (in full)	Male/Female	Date of Birth	Relationship to Applicant	Are they living with you at the moment? Yes/No






b) If any of the above people are not living with you now, please give their present address and the reasons why you are living separately. If you have a child(ren) not living with you permanently please give details if they stay with you at weekends/holidays.

2. LOCAL CONNECTION
You must have a local connection before we can accept you onto our waiting list.
a) Have you lived in the Local Authority Area (i.e. Powys or Ceredigion) for which you are applying for a continuous period of at least 6 months at any time in the past?	Yes	No
Please give details

b) Do you presently live and have lived for at least 6 months prior to your application in the Local Authority Area for which you are applying?	Yes	No
Please give details

c) Do you work in the Local Authority Area or are you moving to the Area to take up permanent employment or enter full time education?	Yes	No
Please give details

d) Do you need to move to the Local Authority Area to benefit from or to give family support?	Yes	No
If YES, please give further details at 10 c)

3. EXCLUSIONS FROM THE WAITING LIST
If you answer YES to any of these questions, we shall not be able to accept you onto the waiting list. Have you or any person named on your application, within the last 5 years:
a) Been evicted by any housing association or local authority for breach of the tenancy?	Yes	No
If YES please give further details

b) Been convicted of criminal acts taking place within any housing association or local authority property, or acts aimed at the property, staff, tenants or neighbours of any housing association or local authority?	Yes	No
If YES please give further details

c) Left the property of any housing association, including Mid-Wales Housing, or local authority, owing rent, unless the debt has subsequently been repaid?	Yes	No
If YES please give further details

N.B. the giving of false information may disqualify any applicant from further consideration, and any tenancy granted as a result of false information can be repossessed by legal action through the County Court.

4. YOUR OCCUPATION
Please give the following details of yourself and all people who will be living with you if your application is successful.
Name	Type of Job	Company/Employer's Name	Length of Employment

5. YOUR PRESENT ACCOMMODATION
Please give details of your present accommodation:
a) Do you live in a
House Bedsit Caravan/Mobile Home Bungalow Flat Hostel/B&B
Other (Please give details)

b) Please state number of bedrooms in your accommodation

c) How many people live in your accommodation?

d) Do you own your present accommodation?	Yes	No

e) If you rent your current accommodation, please give name and address of your landlord

Is your rent up-to-date?	Yes	No
If NO, please give reason and amount outstanding
f) If you neither own nor rent your present accommodation, please give details

g) How long have you lived in your present accommodation?

h) Please state addresses of previous accommodation during the last five years and your reason for moving

6. COMMUNITY CONNECTION
a) Do you presently live or work in the Local Authority Area?	Yes	No

b) Have you previously lived or worked in the Local Authority Area?	Yes	No
If YES, please give details

7. YOUR PRESENT CIRCUMSTANCES
a) Do you have a permanent home of your own?	Yes	No

b) If NO, please give details of present accommodation Please explain why your present accommodation is not permanent (for example, you have been served with a Court Order telling you to leave the property, or you are in tied accommodation which you have to leave, or you are leaving H.M. Forces). Please enclose a copy of the Court Order or correspondence telling you to vacate tied accommodation.

c) If you have not been served with a Court Order to vacate accommodation, have you received correspondence from your landlord, a solicitor or estate agent telling you to vacate the property? If YES, please send us a copy of the correspondence.	Yes	No

8. THE CONDITION OF YOUR HOME
a) Is your present accommodation in a state of disrepair (for example, because of dampness) which prevents you using a bedroom or bedrooms which otherwise would be in regular use?	Yes	No
If YES, please state the number of rooms that are unusable

b) Is there any other room in regular use in your present accommodation severely affected by disrepair - for example, dampness?	Yes	No
If YES, state which room(s) and explain the problem

c) Is adequate heating available?	Yes	No
If NO, please give details

d) Are any of the following facilities not available to you and the people named in your application? If so, please tick each facility that you do NOT have.
Running cold water	Kitchen
Electricity	Running hot water
Plumbed-in inside WC	Wash hand basin
Bath/Shower	Sink

e) Has an Environmental Health Report been completed on your home? If YES, please send us a copy in the post	Yes	No

9. BEDROOMS
a) Do you need a separate bedroom for a single person over 16 years old and named on your application who has no bedroom of his/her own?	Yes	No

b) Do you need a separate bedroom for a single parent or couple presently sharing a bedroom with a child over 2 years?	Yes	No

c) Do you need a separate bedroom for a child over 4 presently sharing with a child of the opposite sex?	Yes	No

d) Do you need a separate bedroom for a child over 4 presently sharing with a child of the same sex?	Yes	No

e) Do you need a separate bedroom because three or more children over 4 years of the same sex are presently sharing?	Yes	No

10. WHY DO YOU WISH TO MOVE?
a) Are you presently living apart from your children (under 18) and would live together if you were able to be rehoused?	Yes	No
If YES, please give details

b) Are you facing increased difficulties in your present accommodation because of:
Age?
Financial problems?
Problems or difficulties in getting to shops, post office etc?
Disability? Physical disability Mental health problems Learning disability
If so, is there someone e.g. a social worker, community psychiatric nurse, doctor or consultant - who will confirm your situation whom we can contact?
If YES - Name
Address
Tel no:

If you have a disability do you need any alterations or adaptations? e.g. a shower instead of a bath, a ramp instead of steps?	Yes	No
If YES, please give details

Do you require ground floor accommodation only? (for information only)	Yes	No

c) Do you need to move or be closer to a relative to give or receive support because of, for example, age or disability?	Yes	No
If YES, please give details including name and address of relative(s) and their relationship to you

d) Do you need to move to be nearer to your job or to take up a new permanent job or to return to full time education?	Yes	No
If YES, how far is your place of work or education from your present home?
Do you have your own transport?	Yes	No
If not, is there a lift or public transport available?	Yes	No

e) Do you need to move because your marriage or partnership has broken down?	Yes	No
If YES, please give details

f) Do you need larger accommodation because of child/children wishing to stay weekends and holidays under access arrangements following divorce/breakdown of partnership	Yes	No
If YES, please give further details

g) Do you have a child or children under 7 years and presently live on the second floor or higher?	Yes	No

h) Do you have a child or children under 7 and presently live on the first floor?	Yes	No

i) Do you have a child or children under 7 and presently live on the ground floor with no enclosed garden?	Yes	No

j) Are there any other reasons that you need or wish to move for?	Yes	No
If YES, please give details
k) Do you need a home of your own because you are presently sharing with other people and you are:
...a single person?
...a couple?
...a single parent?
...living in supported accommodation and requiring independence?
If you have ticked one or more of the above boxes, please give further details

11. ADDITIONAL INFORMATION
a) Are you on the waiting list of:
i) The Council for the Local Authority Area for which you are applying?	Yes	No
ii) Any other housing association?	Yes	No
If you have ticked YES to either of the above how long have you been on their waiting lists?

b) Have you ever applied to this Housing Association for accommodation before?	Yes	No
If YES, when?
For which area/estate?

c) Have you been a tenant of Mid-Wales Housing Association before?	Yes	No
If YES, please give the address and dates of your tenancy

d) Do you have any pets?	Yes	No
If YES, please give details (This information will not prejudice your application in any way, but may affect the type of accommodation that the Association is able to offer you).

12. FURTHER DETAILS ABOUT YOURSELF
Paragraph 2 of Schedule 1 of the Housing Act 1996 allows housing associations to offer accommodation to close relatives of employees and Committee Members in certain circumstances. If you are related to an employee or a Committee Member of this Association, would you please state the name of the person and their relationship to you. Name Relationship

If you would like to give any further information about yourself, your family or your circumstances, or if you would like to send any supporting information that the Association can take into account when considering your application, please do so. You may use the box below for any further information.


In order to enable the Association to deal with your on-line application for housing, please read the following two statements. If you find yourself unable to agree to them, then you must not send this application and you should place a tick in the "No" box at the end of this application. If however, you unconditionally agree with the statements, you should place a tick in the "Yes" box which also appears at the end of this application, and you will then be able to send an application to the Association. For the avoidance of doubt, if you have ticked the "No" box the application will not be accepted by the Association. I/We certify that the foregoing particulars are correct to the best of my/our knowledge and belief, and understand that the giving of incorrect information may result in my/our application being refused or cancelled, or if a tenancy has been offered and accepted, in my/our tenancy being terminated. I/We agree to Mid-Wales Housing Association making enquiries with previous landlords, Social Services, The Probation Service or Police, regarding my/our accommodation history and present housing needs. Yes I agree and wish to send the application No I do not agree and wish to cancel the application

Mid-Wales Housing Association Ltd., Bryn Aderyn, The Bank, Newtown, Powys, SY16 2AB

Company Registration Number - MS21416R | t: 01686 627476 | f: 01686 623195 | e: info@mid-walesha.co.uk

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