HOUSING APPLICATION Please use block capitals when completing this form and provide as much information as possible as this will help us to assess your points accurately. You will need to complete every question that applies to you otherwise your application may be rejected. Please note that before you start your application you will need your National Insurance number, your address history for the last five years and, if applicable, your landlord's contact details for your current and previous addresses. Further details on our housing allocation scheme can be found on our website at www.harrogate.gov.uk. If you need any advice or help to complete this form please contact Customer Services on 01423 500600. OFFICE USE ONLY Date received: Acknowledged: Date logged: Inputting Officer: Application No: Personal details BOROUGH COUNCIL Harrogate Q1 Main applicant Mr/Mrs/Miss/Ms (please delete) Last name First name(s) Date of birth / / Your current address or a contact address Postcode Your contact telephone number Email address National Insurance number Gender: Male/Female/Other (please delete) Next of kin Name Telephone Q2 Joint applicant Mr/Mrs/Miss/Ms (please delete) Last name First name(s) Date of birth / / Please tell us your relationship to the main applicant, for example, spouse, partner. Your current address or a contact address Postcode Your contact telephone number Email address National Insurance number Gender: Male/Female/Other (please delete) Next of kin Name Telephone
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HOUSING APPLICATIONPlease use block capitals when completing this form and provide as much information as possible as this will help us to assess your points accurately. You will need to complete every question that applies to you otherwise your application may be rejected. Please note that before you start your application you will need your National Insurance number, your address history for the last five years and, if applicable, your landlord's contact details for your current and previous addresses. Further details on our housing allocation scheme can be found on our website at www.harrogate.gov.uk. If you need any advice or help to complete this form please contact Customer Services on 01423 500600.
OFFICE USE ONLY
Date received: Acknowledged:
Date logged:
Inputting Officer: Application No:
Personal details
BOROUGH COUNCIL
Harrogate
Q1 Main applicant
Mr/Mrs/Miss/Ms (please delete)
Last name
First name(s)
Date of birth / /
Your current address or a contact address
PostcodeYour contact telephone number
Email address
National Insurance number
Gender: Male/Female/Other (please delete)
Next of kin
Name
Telephone
Q2 Joint applicant
Mr/Mrs/Miss/Ms (please delete)
Last name
First name(s)
Date of birth / /
Please tell us your relationship to the main applicant, for example, spouse, partner.
Your current address or a contact address
PostcodeYour contact telephone number
Email address
National Insurance number
Gender: Male/Female/Other (please delete)
Next of kin
Name
Telephone
Q7 IsEnglishyourfirstlanguage?
Main applicant Yes No
If no, please tell us what your first language is.
Joint applicant Yes No
If no, please tell us what your first language is.
Q6 Which of the following best describes how you think of yourself?
Main Joint applicant applicant
Bisexual
Gay man
Heterosexual/straight
Gay woman/lesbian
Other
Prefer not to say
Q3 Details of your relationship status (please tick):
Main Joint applicant applicant
Single
Married/Civil Partnership
Partner
Separated
Divorced
Co-habitee
Widow
Widower
Do not wish to declare
Q4 Your ethnicity (please tick):
Main Joint applicant applicant
Asian or Asian British Bangladeshi
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British other
Asian
Bangladeshi
Black or Black British African
Black or Black British Caribbean
Black or Black British other
Black African
Black Caribbean
Black other
Chinese
Gypsy Roman Traveller
Indian
Mixed other
Mixed White Asian
Mixed White and Black Caribbean
Mixed White and Black African
Pakistani
White
White British
White other
Other
Do not wish to declare
Q5 Please enter your religion: Main Joint applicant applicant
Buddhist
Christian
Hindu
Jewish
Sikh
Muslim
Other
No religion
Prefer not to say
Q8 Do you need this information translatedintoanotherlanguage?
Yes No
If yes, what language do you want this translating into?
We want to shape our housing service to meet the needs of our customers and to make sure that everyone is treated fairly and able to access the service as easily as possible. Questions 3 to 9 are not compulsory but the information you provide will help us to do this.
Q9 Does anyone in the household have a disabilityundertheEqualityAct?
Yes No
The definition of a disability according to the Equality Act 2010 is: “A physical or mental impairment which has a substantial and long-term adverse effect on his or her ability to carry out normal day to day activities”. Long-term means more than 12 months. The definition covers long-term illnesses such as cancer and HIV or mental health; it includes any adult or child living permanently in the household.
If you answered 'yes' to the previous question please answer the further questions about disability below. If you would prefer not to answer these questions, please leave them blank. However, if you are happy to answer them please put a tick against each one that applies.
Physical disability
Visual impairment
Speech impairment
Hearing impairment
Mental health problems
Long term illness
Difficulties reading or writing
Learning disability
Disability not listed above
Please give details here
Prefer not to say
Household personal details (other adults)Q10 Please give details of everyone
who needs housing with you.
Mr/Mrs/Miss/Ms (please delete)
Last name
First name(s)
Date of birth
National Insurance number
Gender: Male/Female/Other (please delete)
Relationship to you for example mother, son.
Mr/Mrs/Miss/Ms (please delete)
Last name
First name(s)
Date of birth
National Insurance number
Gender: Male/Female/Other (please delete)
Relationship to you for example mother, son.
If you need to list more adults who need housing with you, please use the space provided in the 'Additional Information' section on the back page.
Household personal details (children)Q11 Please give details of children who
need housing with you.
Last name
First name(s)
Date of birth
Gender: Male/Female/Other (please delete)
Relationship to you for example son, daughter.
Do you receive child benefit for them? Yes No
Last name
First name(s)
Date of birth
Gender: Male/Female/Other (please delete)
Relationship to you for example son, daughter.
Do you receive child benefit for them? Yes No
Last name
First name(s)
Date of birth
Gender: Male/Female/Other (please delete)
Relationship to you for example son, daughter.
Do you receive child benefit for them? Yes No
If you need to list more children who need housing with you, please use the space provided in the 'Additional Information' section on the back page.
Main applicant addresses Q12 Starting with your current address, please tell us where you have lived over thelastfiveyearsandwhoownedtheproperty, for example private landlord, council, housing association, parents. If you arecurrentlyofnofixedabode,youmustprovide a correspondence address.
Property OneAddress
Date from / / Date to / /
What is the landlord’s name and address?
Landlord's contact number/email
If not renting, what are your circumstances, for example lodging, owner-occupation.
Property TwoAddress
Date from / / Date to / /
What was the landlord’s name and address?
Landlord's contact number/email
If not rented, what were your circumstances, for example lodging, owner-occupation.
Why did you leave?
Q14 Ifyouarecurrentlyofnofixedabode,or lodging with family/friends on a temporary basis, please provide details of any rent arrears you accrued at your last settled address.
Q15 Have you or anyone included in this application ever had a tenancy in a Harrogate Borough Council property that is not your current property or a propertyalreadymentioned?
Yes No
If yes, please provide details
If you need to list more properties, please use the space provided in the 'Additional Information' section on the back page.
Property ThreeAddress
Date from / / Date to / /
What was the landlord’s name and address?
Landlord's contact number/email
If not rented, what were your circumstances, for example lodging, owner-occupation.
Why did you leave?
Property FourAddress
Date from / / Date to / /
What was the landlord’s name and address?
Landlord's contact number/email
If not rented, what were your circumstances, for example lodging, owner-occupation.
Why did you leave?
Q13 If you are liable for rent in your current property,areyouinrentarrears?
Yes No
If Yes, please provide details.
Property OneAddress
Date from / / Date to / /
What is the landlord’s name and address?
Landlord's contact number/email
If not renting, what are your circumstances, for example lodging, owner-occupation.
Property TwoAddress
Date from / / Date to / /
What was the landlord’s name and address?
Landlord's contact number/email
If not rented, what were your circumstances, for example lodging, owner-occupation.
Why did you leave?
Property ThreeAddress
Date from / / Date to / /
What was the landlord’s name and address?
Landlord's contact number/email
If not rented, what were your circumstances, for example lodging, owner-occupation.
Why did you leave?
Property FourAddress
Date from / / Date to / /
What was the landlord’s name and address?
Landlord's contact number/email
If not rented, what were your circumstances, for example lodging, owner-occupation.
Why did you leave?
Joint applicant addresses Please provide this information if the address history differs from that of the main applicant.
Q16 Starting with your current address, please tell us where you have lived over thelastfiveyearsandwhoownedtheproperty, for example private landlord, council, housing association, parents. If you arecurrentlyofnofixedabode,youmustprovide a correspondence address.
If you need to list more properties, please use the space provided in the Additional Information section on the back page.
Q17 If you are liable for rent in your current property,areyouinrentarrears?
Yes No
If Yes, please provide details
Q18 Ifyouarecurrentlyofnofixedabode, or lodging with family/friends on a temporary basis, please provide details of any rent arrears you accrued at your last settled address.
Q21 What is your local connection to thedistrict?
Our local connection criteria is explained on our website www.harrogate.gov.uk/localconnection in the housing allocation scheme summary information booklet.
In addition to your five year address history detailed in questions 12 and 16, please provide any additional local connection details (for example name, address, relevant dates of residency/employment).
Previous resident - this applies if you have previously lived in the district for a continuous period of ten years.
Family who live in the area (please give full details of their names, addresses, relationship to you and how long they have lived in the Harrogate district).
Your current employment details.
Your current circumstances
Q20 Inthepastfiveyears,ifyouoranyone moving with you have come to live in the UK or returned to the UK from living abroad, please provide their name, the country they entered the UK from, and the date they entered the UK.
Q19 If you or any of the people moving with you are not UK citizens, please providedetailsandconfirmwhichcountry they are a citizen of.
Q22 Are you a current or former member of the Reserves/Armed Forces serving atanytimeinthefiveyearsprecedingyourapplicationforhousing?
Please give details of length of service and service personnel number.
Q23 Are you a bereaved spouse or civil partner who can no longer live in Ministry of Defence accommodation following the death in service of yourspouseorpartner?
Please give details
Q24 Are you a social housing tenant living in England, needing to move into the district to take up an offer of employment?
Please provide details
Q25 Does any member of the household ownapropertyanywhereintheworld?
Yes No
Q26 Is the combined household income morethan£60,000peryear?
Yes No
Q27 Are the combined household savings morethan£120,000?
Yes No
Q28 Are you or any of these people to be rehousedwithyouexpectingababy?
Yes No
If yes, please state their name and when the baby is due.
Q29 Doyouhaveanypets?
Yes No
If yes, please give details.
Q30 Medical factors
Please give details of yourself and anyone wishing to be housed with you who is suffering from a serious illness or disability that is affected by your accommodation.
First Person
Last name
First name(s)
Name and address of doctor
Name of occupational therapist (if applicable).
Details of illness / disability and reasons why your current accommodation is no longer suitable.
Second person
Last name
First name(s)
Name and address of doctor
Name of occupational therapist (if applicable).
Details of illness / disability and reasons why your current accommodation is no longer suitable.
If there are any other people with a medical condition, please give details in the 'Additional Information' section on the back page.
Q32 Details of any convictions.If you or anyone included in this application has ever been convicted of a criminal offence, or been involved in any inappropriate activity, such as anti- social behaviour, please give details.
Name
Date of offence(s)
Details
Your current homeQ33 What type of home do you
liveinnow?(Please tick)
House
Flat
Bungalow
Maisonette
Mobile home size
Bed and breakfast
Bedsit
Shared House
Hostel
Other (please specify)
(specify feet or metres)
Q34 What floor is your current accommodationon? (Please tick)
Ground First Second
Other (please specify)
Q35 What type of amenities doyouhave? (Please tick) Yes No
Living room
Separate kitchen
Separate bathroom
Inside toilet
Hot water supply
Cold water supply
Q36 Do you share any of these rooms with someone NOT beingrehousedwithyou? (Please tick) Yes No
Living room
Dining room
Kitchen
Bathroom
Toilet
Q31 Is there anyone who you would like to support your application - such as a social worker or care assistant, or a friend or relative who provides careorsupport?
Please give their full name, address and contact telephone number.
Do you think you will need additional support if we are able to offer you accommodation, for example budgeting, or understanding correspondence?
Q41 If you have been asked to leave your present accommodation please give details.
Please provide written proof.
What is the date you have to leave by?
Who asked you to leave?
Why do you have to leave?
About the home you want
Q42 What type of home do yourequire? (Please tick)
House
Bungalow
Maisonette
Bedsit - ground floor only
Bedsit - any floor
Flat - ground floor only
Flat - any floor
Please state your reasons for applying.
Q43 Do you require adapted accommodation?
(Please tick) Yes No
Level access shower
Full wet room
Ramped access
Fully wheelchair accessible
Stair lift
Through floor lift
Grab rails for bathing or toileting
Grab rails - other
Multiple adaptations
Q44 Does any member of your household need their own bedroom for medical reasons?
Yes No
If yes, please specify who and why.
Q37 How many bedrooms are there in yourhome? (Please tick ‘Single’ or ‘Double’ and whether it is for you/your family’s 'Sole Use')
Single Double Sole Use Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Q38 Do you have a garden/enclosed yard?
Yes No
Q39 Is your home in a poor state ofrepair?
Yes No
If ‘yes’ please give details?
Q40 What is your current accommodation type? (Please tick)
Secure tenancy
Assured Shorthold tenancy
Assured Shorthold tenancy with notice to quit (Section 21 Notice)
Assured tenancy - housing association
Hospital and no other accommodation
Lodger
Owner-occupier
In prison and due for release
Living with relative/friends
Sleeping rough
Tied accommodation
Temporary accommodation
Other
3 Ripon 03010 Lead Lane
03020 Holmefield
03S17 Russell Dixon Square
03030 Northern
03040 Central
4 Boroughbridge 04270 Cundall
04460 Skelton-on-Ure
04470 Kirby Hill
04630 Roecliffe
04640 Boroughbridge
04S24 Springfield, Boroughbridge
0464L Langthorpe
0464M Minskip
5 Knaresborough Villages 05101 Goldsborough
05102 Flaxby
05700 Staveley
05780 Arkendale
05830 Scotton
05850 Ferrensby
Location choicesQ45 You are able to choose the location of your preferred accommodation, although YOU MUST CHOOSE A MINIMUM
OF FOUR out of the sixteen main lettings areas across the Harrogate district and one of those areas must include either Harrogate, Knaresborough or Ripon. If you don't choose four areas, your application will be rejected. Please indicate the four or more areas you would like to be considered for by ticking the boxes below. Please refer to the map showing the letting areas. It is advisable to widen your choice as much as possible, but for more rural areas please check the availability of facilities such as public transport before making your choices. You will receive a maximum of two offers of accommodation. You may select up to 16 areas. THIS DOESN'T APPLY IF YOU ARE SPECIFICALLY INTERESTED IN SHELTERED HOUSING. PLEASE SEE Q46 FOR MORE INFORMATION ON SHELTERED HOUSING AND THE INDEPENDENT LIVING SERVICE.
ConnectionsQ47 Employees of housing providersDo you, or anyone in your household, or anyone related to you, work for any of the housing providers you have applied to? Yes No
If ‘yes’ please give their name and who they work for:
Q48 Elected member or members of staff
Are you, or any member of your household, related to any Harrogate Borough Council elected member, or member of staff? Yes No
If ‘yes’ please give their name and relationship to you:
Name of relative
Relationship to you
Independent Living ServiceQ46 The council has six sheltered housing schemes of purpose built flats with an emergency call system for people aged 60 or older who are still able to live independently, but who would benefit from the security and the support of an Independent Living Officer.
These schemes are Carlton Lodge - Harrogate; Collins Court and Hewitson Court - Knaresborough; Bondgate Court and Blossomgate Court - Ripon and Maple Creek - Masham.
Sheltered Housing Schemes
01S08 Carlton Lodge 02S11 Collins Court
02S10 Hewitson Court 11S18 Maple Creek
03S15 Bondgate Court 03S16 Blossomgate Court
Harrogate Lifeline ServiceWe also offer an Independent Living Support service for anyone aged 60 years or older. This is available to anyone - social housing tenants, homeowners or those renting privately. Support is provided by an Independent Living Officer, via a Lifeline unit using the property's telephone land line. To be considered for either our sheltered housing accommodation or Harrogate Lifeline Service you will be asked to complete a needs assessment to identify your particular needs and the support you require. Although both these types of support are principally for people aged 60 years or older, we also consider other vulnerable people subject to a support needs assessment.
If you are interested in Older Persons Independent Living Support Service and you need some additional support, please provide brief details of your needs in the 'Additional Information' section on the back page.
HomeSwapper Mutual Exchange ServiceIf you are an existing social housing tenant we recommend that you register for a home swap at www.homeswapper.co.uk
DeclarationQ49 Please read this declaration carefully and then sign it. If you are applying
jointly, you both need to sign it. To find out what your rights are please go to our website www.harrogate.gov.uk/privacynotice
I/we consent to the council obtaining/releasing information to other landlords/landlords’ agents/professional housing organisations/government agencies/medical professionals if necessary relating to my/our application.
I/we explicitly consent for North Yorkshire Police to disclose details of my/our previous criminal convictions, any risk assessments they have carried out, or agencies they know to have carried out risk assessments in relation to me/us; also, any information that the police may have relevant to future crime prevention and community safety issues relating to me/us to Harrogate Borough Council for the purpose of permitting them to manage any risk, and reduce potential for future re-offending.
I/we understand that the information contained on my/our application may be released to the Audit Commission in respect of the National Fraud Initiative to detect fraud against the public purse and the council may share this information for the same purposes with other organisations that handle public funds.
I/we understand that if I/we have come to live in this country within the last five years, the council may have to approach the Home Office to check the information I/we have given in this form and to obtain further related information.
I/we understand that legal action may be taken against any person who obtains accommodation as a result of giving false or misleading information or withholding information which has been requested.
I/we will inform the council in writing if my/our circumstances change.
Applicant’s signature Date
Joint Applicant’s signature Date
Please use this space to note any additional details to support your application.
Please return this form to: Housing and Property, Harrogate Borough Council, PO Box 787, Harrogate, HG1 9RW.