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Home , Chelmer Village, Good Easter, Great Baddow, Great Leighs, Little Baddow, Little Waltham

Immediately available homes application

This form is for adults aged 50+ or 60+ (they can have children who are 18 or above). These are properties which are often hard to let and have already been advertised by City Council and CHP unsuccessfully. When a property becomes available, the shortlist is based on priority date.

Once complete, please return this form to:

Myriad House, 33 Springfield Lyons Approach, Chelmsford, . CM2 5LB. Or email [email protected]. If you do not have access to the internet or would like assistance you can contact the Customer Service Centre on 0300 555 0500.

We need this information in order to enter into a contract with you as well as to satisfy our legal obligations to understand and assess your housing needs. By filling out this form, you are helping us assess your housing needs, please see www.chp.org.uk/privacy for more information on how we look after your data.

1. Household details

Starting with yourself, please provide details of everyone currently living in your household. Title: First name: Surname: Relationship to applicant Date of birth:

2. Details of current accommodation

Current address (including postcode):

Home telephone: Mobile telephone: Email: Date moved in: Owned/rented: Property type (e.g one bed flat): Local Authority: Landlord:

1 If you have lived at your current address for less than five years, please give your previous addresses for the last five years: Address (include postcode): Date moved Date moved Landlord: Reason for leaving: in: out:

Do you currently own, any other property here or abroad? Yes No

If yes, please state address: Is this property subject to be sold Yes No

What is the main reason for wanting to move from your last settled home?

Do you have any pets that you would want to live with you? Yes No

If yes, please provide details:

3. Disability

Are you registered disabled? Yes No

To ensure we are aware of your housing needs, please advise us if any of the three options below apply to any persons named in sections on your application who will be moving in with you. Options: Name of person(s) with mobility needs: A member of my household needs to 1 use a wheelchair both inside and outside my home.

A member of my household is unable to 2 manage steps and stairs and may use a wheelchair some of the day.

A member of my household is only able 3 to manage one or two steps or stairs.

2 Do you require a wheelchair accessible property? Yes No

If the property had lift access, could you manage stairs in the Yes No event of an emergency and the lift could not be used?

What type of bathroom would meet your needs (tick all that apply): Bath Step in shower tray

Level access Any wet room

What type of external entrance could you manage (tick all that apply): Level access One or two steps Any Communal doors Ramped access

What type of property would suit your needs? Ground floor flat First floor flat Studio flat

4. Additional support

Please tick the box(es) below if they apply to you. Please note, if you tick any of the boxes we may contact you for further information.

Learning disability Serious illness Previous victim of abuse / crime and / or violence Depression Physical disability Literacy issues or English is not first language Deaf Mental health issue Deaf and blind Communication difficulties

History of rough sleeping Visually impaired Evicted from previous home Problems with alcohol Homeless with support needs Drugs misuse

Recently bereaved

5. Criminal convictions

Have you, or any household member, ever been convicted of any criminal offences?

Yes No If yes, name:

Is the person named above currently on bail / probation? Yes No

If yes, please give details of your probation office / prosecuting officer:

3 Has the person named above ever been charged with any offence Yes No that is pending prosecution? If yes, please give details:

Is there any other information you would like us to consider:

6. Where would you like to live? On the next two pages, please tick all areas you are interested in moving too. CHP Designated Elderly & Sheltered Accommodation in Chelmsford Borough

10

19

11 14 8

5 2

1 29 18 33 4 31 23 17 13 28 3 20 32 34 16 6 9 26 25 12

7

15

30

27

22 21

24 Ordnance Survey data © Crown copyright and database right 2018

Each map marker is labelled with a CHP Property Count number that corresponds to the 1-10 location name on the reverse side of 11-50 4 this map 50+ Each map marker on the map opposite is labelled with a number that corresponds to the locations listed below. Please tick all areas within Chelmsford that you are interested in moving to.

I am interested in all areas.

I am only interested in the following areas (tick all that apply):

1. 18. Newland Spring

2. Broomfield 19.

3. 20. Rainsford 4. Chignall 21.

5. Chignall St James 22.

6. Danbury (Runsell Green) 23.

7. 24.

8. 25. Sandon

9. 26. Sawkins Est

10. 27. South

11. 28. Springfield 12. Highwood (Edney Common) 29. Springfield North

13. 30. Stock

14. 31. Town Area North

15. 32. Westlands Est

16. Meadgate Est 33. Woodhall Est

17. Melbourne Est 34.

7. Alternative contact

Name of contact Relationship to applicant Contact number:

Emergency contact information:

5 Declaration

I / We hereby confirm that the information given in this application is true. I / We understand that any misleading or false statements may result in the cancellation of this application. I / We agree to inform CHP about any changes within my household that would affect my immediately available homes application. I / We have just completed and signed a CHP Immediately available homes application and agree that CHP may: • Share information with local authorities regarding my / our application for housing, including copies of verification documents and identification; • Contact previous landlords regarding my / our tenancy history. If you complete this form we’ll store and process your data in accordance to the requirements of our Data Protection Policy and in keeping with the Data Protection Act. We may supply information to other organisations such as contractors working for us, the police or local authorities in order to manage your tenancy and help us manage our neighbourhoods. We maintain a register of vulnerable or potentially violent individuals in their properties. You’ll be informed if you’re placed on this register. This information may be shared with concerned parties without your consent. I undertake to notify CHP of any changes to these details; I understand that I will be required to verify the information supplied by my on this form; I understand that landlord references will be required.

Applicants signature: Print name: Date:

Where did hear about our available homes?

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7 Please complete your name and address in the space below. CHP will send this page back to you as confirmation that your form has been received.

Title: First name: Surname: Address (please include postcode):

Thank you for your immediately available home application received on

The housing options team will contact you if we require any further information.

All available properties are shown on our websitewww.chp.org.uk .

We will only contact you when you reach the top of the shortlist for an available property that meets your needs as outlined in this form. We may contact you annually to update this information if we have been unable to offer you suitable accommodation.

I understand that if I am short-listed for a property, an offer is subject to a satisfactory assessment form and reference and the following will need to be provided:

ID: Passport, driving licence Proof of income: Wage slips, benefits letters Proof of address: Bank statements, utility bills Medical evidence: If applicable.

Please ensure you update us if your circumstances change. Yours sincerely Housing options team

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