Salvation Army Housing Association Housing Application

For help in completing this form, please contact the Customer Services Centre (Tel:
0800 970 6363)

Customer Services Centre Address:

33-35 Chorley New Road, Bolton, BL1
for:______________
4QR Telephone: 0800 970 6363
Fax: 01204 375768

Scheme/Project applying
______________________________________

Please complete all the questions. We will not be able to process you application
otherwise.

PERSONAL DETAILS
Applicants name (Mr, Mrs, Miss, Ms) __________________________________________________
Address _________________________________________________________________________
__________________________________________________ Postcode _____________________
Telephone number (daytime) __________________________ (evening) ____________________
(mobile) _____________________ email address ________________________
Next of kin _________________________________________Telephone number ______________
Contact address if different from above
________________________________________________
National Insurance number _________________________________________________________
Are you related to an employee/member of the Salvation Army Housing Association?
If yes, who? _____________________________________________________________________
Have you ever been cautioned or convicted of a criminal offence? Yes No
If yes, please give details of all offences and
dates_______________________________________
Has the conviction been spent? Yes No
Please give details of any current probation or other kind of community order. Include
any current or previous bail
conditions___________________________________________________________

YOUR HOUSING NEEDS

TYPE

WHO

OF ACCOMMODATION APPLYING FOR

Elderly 60+
Single Person/Couple
Family

Accommodation With Support

Foyer
Supported Scheme

NEEDS TO BE REHOUSED?

Please give details of everyone who needs to be re-housed, starting with yourself:
SURNAME

FIRST

NAME

MALE

OR
FEMALE

AGE

DATE
BIRTH

OF

REGISTERED

RELATIONSHIP

DISABLED

TO YOU

Applicant

DO

THEY
LIVE WITH
YOU?

Are you, or any of the people to be rehoused with you, expecting a baby? Yes No
If yes, who is expecting and when is the baby due?
______________________________________
(Please attach proof of pregnancy, ie, copy of certification or confinement.)
Do you, or anyone moving with you:
Have difficulty climbing stairs
Need ground floor
accommodation
Use a wheelchair in the house
Require special adaptations
If yes, please give details

WHERE

DO YOU LIVE AT THE MOMENT?

Local Authority accommodation

Housing Association/Registered
Social Landlord

Private Tenant

Hostel/shared supported housing

Owning or buying
Living with friends/family
Self-contained supported housing
tenant
Approved probation/bail hostel

DETAILS

Childrens home/foster care

Hospital
Prison
Residential care home
Bed and breakfast
Squatting
Sheltered accommodation
No fixed abode
Other
____________________________

OF YOUR PRESENT HOME

How many bedrooms does your present home have? _______

DO

YOU HAVE (TICK ONE BOX ONLY):

YES

NO

SHARED

IF SHARED, WHO WITH

Use of a bath or shower

An inside toilet
A separate bedroom
A separate kitchen
Central heating or storage
heaters
A hot water supply

PROPERTY

CONDITION

Does your home have any of the following:

Leaking roof

WHO

Dangerous electrical wiring

Severe damp

Rain water penetrating property

Other, please describe
_____________

ELSE CURRENTLY LIVES WITH YOU WHO IS NOT MOVING WITH YOU?

SURNAME

FIRST

NAME

MALE

OR
FEMALE

AGE

DATE
BIRTH

OF

REGISTERED

RELATIONSHIP

DISABLED

TO YOU

DO

THEY
HAVE THEIR
OWN ROOM?

WHY DO YOU WANT TO MOVE?

To be rehoused from short-stay

hostel

To get away from other

harassment

To be rehoused from an
institution

To get away from domestic

violence

To move-on to supported selfcontained housing

I have problems relating to

physical health

To receive higher support

I am a refugee/asylum seeker

I have been asked to leave home

I am on a probation service order

I am a rough sleeper

Other
______________________________

HOW

I need specially adapted

accommodation
To leaving home of family or
friends by choice
To get away from racial
harassment

To get help with alcohol/drug

rehabilitation
I have been evicted from my
housing

WOULD YOU DESCRIBE YOUR CURRENT ECONOMIC STATUS?

Working full-time
Working part-time
Training full-time
Training part-time
Voluntary Work
Foster Parent
Full-time carer
Unemployed
Retired

Student

Sick
Higher Education
Further Education
Job Seeker Allowance
Incapacity Benefit
Income Support
Disability/ DLA
Prefer not to say
Other (please
state)______________

Home not seeking work

Are you in receipt of any welfare benefits?

If yes, which ones_________________________________________________________________
If no, what is your weekly income? __________________________________________________
Do you have any debts or outstanding housing arrears? (Please give details)
_________________
If you must leave your present address, what date must you leave by?
_____________________

DO

YOU QUALIFY FOR ANY OF THE FOLLOWING?

Housing Benefit

Residential Allowance

Neither HB or Residential
Allowance

If you are a tenant in your current

property, please provide the Landlords
name, address and telephone number:
________________________________________
________________________________________
________________________________________
________________________________________
_________________________
If you are the owner, or part-owner of
this property:
How much is the property worth?
______________________________
How much of your mortgage is left to
pay? ______________________________
Number of years left on your mortgage
____
(Your building society or lender will tell
you.)
Is the property currently for sale?
Yes No

Dont know

Do you, or anyone to be rehoused with you, own any other properties? Yes No
Have you sold any properties within the last 5 years?
If yes: Address of sold property ______________________________________________________
Date of sale _________ Sale price ___________ Amount of equity/capital gained
______
Do you, or anyone being rehoused with you, keep any pets? Yes No
If yes, please say what type of pet you have and how many?
______________________________
Have you applied to the Salvation Army Housing Association in the past? Yes No
If yes, when? ____________________________________________________________________
Are you on a Councils waiting list? Yes No
If yes, which one? ________________________________________________________________
Are you any other Housing Associations waiting list? Yes No
If yes, which one? ________________________________________________________________

REFERENCES
Please give details of your addresses over the last 10 years. If you have not held a
tenancy previously, please give details of two persons who could provide a personal
character reference.
From

To

Reason for leaving

Others

You

Previous address

Name & Address of Referee

Relationship to
applicant

Date known since

ADDITIONAL INFORMATION
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Statement
Please read this declaration and sign below.
I understand that the Association will decide whether to allocate a tenancy/licence agreement
based on the information on this form. The information I have given is true and complete to the

best of my knowledge. I will tell the Association if my circumstances change. The Association
reserves the right to apply to the courts to take back any tenancy/licence agreement that is
given based on false information.
It is the Associations policy to grant joint tenancies wherever applicable for general
needs accommodation. All applicants who wish to be included on the tenancy/licence
agreement and are over the age of 16 must sign below.
Signed _______________________________________________
Date _____________________
Signed _______________________________________________

Date _____________________

Information supplied on this form may be put on our computer and used as part of our
allocations policy. We will treat the information you give us as confidential and will only use it
to assess your housing needs. Before returning this form, please make sure ALL questions
are answered fully. Please return the completed form to address on the front of the form.

EQUAL OPPORTUNITIES MONITORING FORM

The Association operates policies designed to ensure that all applicants receive equal
treatment, regardless of their ethnic origin, sex or physical disability. To enable the
Association to monitor whether its policy is fully carried out, will you please provide
the following information. This information will NOT affect your application, and if you
would prefer not to answer the questions, this view will be respected.

FIRST APPLICANT
How would you describe your ethnic origin?

White British
White Irish
White other
Mixed: white & black Caribbean
Mixed: white & black African
Mixed: white & Asian
Mixed: other
Asian/Asian British: Indian

Do you consider yourself to have a

disability? Yes No
Do you use a wheelchair?

Asian/Asian British: Pakistani

Asian/Asian British: Bangladeshi
Asian/Asian British: other
Black/black British: Caribbean
Black/black British: African
Black/black British: other
Chinese
Other

Sikhism

Yes No

What is your religion?

Christianity
Hinduism
Islam
Judaism

Buddhism
No religious beliefs
Prefer not to say

 Other (please
state)__________________
Are you: Male

Female

SECOND APPLICANT
How would you describe your ethnic origin?

White British
White Irish
White other
Mixed: white & black Caribbean
Mixed: white & black African
Mixed: white & Asian
Mixed: other
Asian/Asian British: Indian

Asian/Asian British: Pakistani

Asian/Asian British: Bangladeshi
Asian/Asian British: other
Black/black British: Caribbean
Black/black British: African
Black/black British: other
Chinese
Other

Do you consider yourself to have a

disability? Yes No
Do you use a wheelchair?

Yes No

What is your religion?

Buddhism

Christianity

No religious beliefs

Hinduism

Prefer not to say

Islam

Other (please

Judaism

state)__________________

Sikhism
Are you: Male

Female