Housing Application Form

Please complete this online application for accommodation if you wish to go on our waiting list.

Before completing the form, please read through our Lettings Policy.

To help us provide a quick and efficient service, please ensure that you answer the questions in full.

Should you require any assistance in completing the application form, please do not hesitate to contact the Association on 0300 111 3030.

YOUR PERSONAL DETAILS

Applicant 1			Applicant 2
Are you a Mid Wales Housing Tenant? Yes No			Are you a Mid Wales Housing Tenant? Yes No
Mr Mrs Miss Ms			Mr Mrs Miss Ms
Name			Name
Address line 1			Address line 1
Address line 2			Address line 2
Town			Town
County			County
Postcode			Postcode
Correspondence Address (if different)			Correspondence Address (if different)
Address line 1			Address line 1
Address line 2			Address line 2
Town			Town
County			County
Postcode			Postcode
Home Phone			Home Phone
Other Phone			Other Phone
Email Address			Email Address
Date of Birth			Date of Birth
Relationship to 2			Relationship to 1
Are you related to any member of Mid Wales Housing's staff or Board of Management? Yes No			Are you related to any member of Mid Wales Housing's staff or Board of Management? Yes No
If yes, please state name and relationship to you			If yes, please state name and relationship to you
Is your right to live in the UK restricted in any way? Yes No			Is your right to live in the UK restricted in any way? Yes No
If yes, please explain how			If yes, please explain how

YOUR HOUSEHOLD
Other than applicants 1 and 2 please list everyone wishing to be re-housed with you
First Name	Surname	Date of Birth	Age	Relationship to You	Currently living with you? Yes/No






If you are a tenant, please give us the name and address of your landlord.

Name
Address Line 1
Address Line 2
Town
County
Postcode

MUTUAL EXCHANGE

If you are a tenant of a Housing Association or a Local Authority would you be interested in swapping your current home with another tenant in the area of your choice? This is known as a mutual exchange	Yes	No

YOUR REASONS FOR HOUSING
Please explain in detail your reasons for applying for alternative accommodation and provide us with appropriate documentary evidence.
If you wish to attach a copy of any relevant information to your application, you may do so by using the Browse facility below. Only one document of the following types can be attached: - Microsoft Word (.doc or .rtf), Adobe Acrobat (.pdf) or Text Files (.txt). Please Note: The application form must always be completed in full, as your documentation alone cannot be accepted.

YOUR CURRENT HOUSING
In the following table, please put a tick in the relevant box to show the type of accommodation where you currently live.
Are you homeless	Yes	No
Have you received a homeless decision from the Local Authority?	Yes	No

Rented from the council		Travelling
Rented from a housing association		Temporary accommodation (hostel or b&b)
Privately rented		Local authority care
A home you own		Children's home or foster care
Living with parents		Living with other relatives
Staying with friends		Hospital (medical reasons)
Mobile home		Refuge
Fixed caravan on site		Sleeping rough
Armed forces		Prison
Supported lodgings (i.e. sheltered housing)		Other (please state below)

How long have you lived in your current property?		Years	Months
What type of property do you live in?
House	Bungalow	Flat	Bedsit
Other:
How many bedrooms do you have use of?
If you live in a flat or bedsit, what floor is it on?

Does the property lack any of the following facilities?
Inadequate/lack of a water supply		Bath or shower
Hot water supply		Electricity supply
Inside toilet		Cooking facilities
Sink or wash hand basin		Lack of access to garden for children
Heating

Are you sharing facilities with anyone else?	Yes	No
Are you presently living apart from your partner and/or children (under 18) and would live together if you were able to be rehoused?	Yes	No
Has an environmental health report been completed on your home? If yes, please attach a copy of the report.	Yes	No
Do you or a member of your household have a medical condition that would significantly benefit from early rehousing in suitable accommodation?	Yes	No
If yes, please state

YOUR HOUSING NEED
Are there any facilities/adaptations in your current home that are no longer required?	Yes	No
If yes, please state
Do you need to move?
In order to give or receive essential support?	Yes	No
If YES is it to:
Meet the needs of a disabled member of the applicant's household?	Yes	No
Where someone applying to be housed is registered to provide foster or respite care?	Yes	No
Do you need to move due to travel difficulties?
Where essential journeys are impossible due to lack of suitable transport or can be undertaken at considerable expense or poses a health risk to someone applying to be rehoused?	Yes	No
(These points will only be awarded where applicants are faced with unavoidable and difficult journeys in respect of employment, the schooling of children, medical or social reasons, points will not be awarded where the difficulty is as a result of personal choice)
Do you have any pets?	Yes	No
If yes, please give details

YOUR CHOICE OF AREA(S)
Please give details of the area(s) where you require re-housing, and tick whether or not you have a connection to that area. Local Connection means that at least one person applying to be housed has lived in or been principally employed in the area requested for a period of at least 12 months at the date of the application OR has previously lived in the area requested for a period of at least 3 years.

Area(s)	Local Connection
	Yes	No
	Yes	No
	Yes	No
	Yes	No
	Yes	No
	Yes	No

Does the household have a specialist need?:		Please tick
Ground floor accommodation required
Accommodation for older persons with support services provided required
Level access shower required
Wheelchair accessible property required
Wheelchair adapted property required
Other requirements (please specify)


SUPPORT IN YOUR HOUSING
This section will help us to find appropriate support for your tenancy, if required. Please note that this section is OPTIONAL and you can skip it if you do not wish to complete it.

If an agency worker is helping fill in this form, please say who they work for in the space below
The table below is a list of the type of things you may need support for. We need to know which of these issues affect you. We also need to know how important these issues are to you, and how much support you need. For each issue that affects you, please put a tick in one of the columns to show how much support you think you will need.
Type of need	No support	A little support	Some support	A lot of support
Domestic abuse
Learning disabilities
Mental Health issue
Alcohol misuse
Drug misuse
Refugee
Physical disability or mobility issues
Young and in need of support
Offending issues
Homeless or at risk of being homeless
Chronic (long term) illness
Need support because of being a vulnerable parent
Elderly person and in need of support
Other (please say)

From the table above, please say which ONE of these you feel is the most important to you.


Do you have any other issues relevant to your housing and support needs? Please tick all that apply.
Issues to do with sexuality		Any particular health issues
Safety and confidential address		Mobility problems
Autism spectrum disorder		Traveller
Hearing difficulties		Sight difficulties
Financial problems		Young people leaving care
HIV positive		Other

Please tell us if you need support with any of the following? Please tick all that apply.
Help with feeling safe and secure within your home and within the community
Help developing skills and interests and getting a job
Help with managing your home, arranging gas, electricity and water supplies, arranging for someone to maintain or repair your home
Help with managing your money (for example paying bills, budgeting, claiming benefits, filling in forms and dealing with letters)
Help with going to the doctor, dentist, meeting your social worker and so on.


Would you need support with other things that are not housing related, such as medical or personal care, which could include washing and bathing and ensuring you are taking your tablets at the right time?	Yes	No
What sort of other things would you need help with?
Are you currently receiving support from an organisation or service?	Yes	No

If yes, please tick the relevant ones from the list below and include any other organisations that help you.
Organisation or service		Please tick
Community psychiatric nurse (CPN)
Community mental-health team
Social services or children’s services
Housing-options advisor or housing officer
Voluntary agency (please say which)
Probation office or youth offending team
Health professionals such as a nurse
Occupational therapist
Other (please say)

EQUAL OPPORTUNITIES MONITORING
Mid Wales Housing Association is committed to the active promotion of Equal Opportunities. Monitoring enables us to identify possible inequalities within our service provision, so that we can make necessary changes for improvement. The information you provide on this form will be treated in the strictest confidence, and will be used simply to provide a statistical profile of the people who access our services. If joint application, please complete for both applicants. Please note that this section is OPTIONAL and you can skip it if you do not wish to complete it.

1. ETHNIC GROUP		2. LANGUAGE
What is your ethnic group? Please choose ONE section from A to E, then tick the appropriate box to indicate your ethnic background		Do you speak Welsh?
		Yes	No
A. White		3. DISABILITY
British	Welsh	The Disability Discrimination Act 1995 defines disability as follows: ‘A person has a disability if he/she has a physical or mental impairment which has a substantial and long term adverse effect on his/her ability to carry out normal day to day activities’ Taking this definition into consideration, do you or any household member consider yourself to have a disability?
	English
	Scottish
	Other
Irish
Other White		Yes	No
Please specify		If, YES please tick which of the following best describes the nature of your disability
B. Mixed
White and Black Caribbean		Visually Impaired	Hearing Impaired
White and Black African		Physical Disability	Learning Disability
White and Asian		Mental Health Disability	Other
Any other mixed background		If OTHER, please state briefly the nature of your disability
Please specify
C. Asian
Indian
Pakistani		4. RELIGION
Bangladeshi		Do you have a religious belief?
Any other Asian background		Yes	No
Please specify		If YES please specify from the list below
D. Black or Black British		Christian	Buddhist
Caribbean		Hindu	Jewish
African		Muslim	Sikh
Any other Black background		Any other Religion/belief
Please specify		Please specify
E. Chinese
Chinese
Any other ethnic background
Please specify

DATA PROTECTION

The information given on this form will be treated with the strictest confidence and in line with the Data Protection Act.

If someone else has completed this form on your behalf please provide their details

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 in the box below.

In order to enable the Association to deal with your on-line application for housing, please read the following three 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 declare that the information provided in this application is correct and understand that if any of it is incorrect or misleading then this may be grounds for the Association to evict me/us, refuse my/our application.

I/We agree to let you know as soon as possible if the circumstances of my/our household detailed on this form change in any way.

I/We give permission for Mid-Wales Housing to contact any third party, (i.e. landlords/doctor/consultant/carer/Social Services/other agencies) for information in relation to this application and 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, Tŷ Canol House, Ffordd Croesawdy, Newtown, Powys, SY16 1AL

Company Registration Number - MS21416R | t: 0300 111 3030 | f: 0300 111 3031 | sms: 07797 885035 | e: info@mid-walesha.co.uk

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