Application to the Court of Protection Referral Form

Appendix 1: Application to the Court of Protection (Tenancy) referral form

Nature of Application (delete as applicable) Termination of Tenancy:

Termination of Tenancy and Finance deputy:

Date of referral:

Contact Details of Practitioner Completing Form- Name:

Job Title

Organisation Address and contact details

Tenant and tenancy details Name : CF/Pimms reference: D.O.B.

Full address of tenancy: BHCC Housing Association Private (delete as applicable) Housing Officer &/or Landlord. Full address and contact details: Full address of placement and date of admission: Full address details of See Guidance - Forms and documents paragraph 5 family or significant others with an interest, who are to notified or included as respondents in the proceedings: Confirm person lacks Date of BI decision to arrange termination of tenancy.

1 capacity in relation to accommodation move and/or to end tenancy If not the referring practitioner , provide full address of GP, Psychiatrist or other practitioner who will be completing the COP3 Attachments  COP24 witness statement (or state when will be  COP3 Mental Capacity Assessment (see above) provided)  Copy of the tenancy agreement  Relevant additional documents cited within COP24 to be included as exhibits.

Funding status - Self Funded LA Funded S117 CHC * Other delete as applicable (details)

CHC* Where a person is fully funded through NHSCHC the responsible nurse practitioner should refer directly to sandra.o’[email protected]

Current income and management of monies Is person already known to BHCC Finance Team? YES/NO If No, does person have : Delete as applicable  Private pension/income: Yes (Provide details) No  Welfare Benefits : Yes (provide details) No  Savings/other assets: Yes (provide details) No Does person have capacity to manage finances? Yes/No If not person or BHCC Finance team, provide address/ contact details of other person/organisation managing:  Relative/friend Solicitor Money Advice/other service No one (delete as applicable)  Nature of authority: Appointee, Lasting or Enduring Power of Attorney. Court appointed Deputy, informal (delete as applicable)

Other relevant information: e.g. someone else living in property, complex tenancy or related issue requiring specialist or legal advice, request to dispense with requirement to notify person included/to be included in application. Is the person subject to an authorisation under the Deprivation of Liberty Safeguards, or is such an authorisation indicated?

Confirmation of Managers’ approval: Name: Contact details:

Once completed in full please email to: ASCincomessection@brighton- hove.gov.uk and copy email to authorising manager.

2 Once issued, the Financial Assessment Team will forward the Court Order to you, to make the appropriate arrangements to end the tenancy, and will be copied to the housing officer/landlord.

August 2016