Application for Housing Dumfries and Galloway Common

Application for Housing

Dumfries and Galloway Common Housing Register

(Coming 2018/2019)

Available for translation into community languages, large print and formats such as Braille on request Declaration Guidance Notes Before completing this form please read through the following statements and sign at the Please print clearly and answer all the questions as fully as possible. If you need support to complete bottom to show that you understand and agree with them. this form, please call us on 0300 123 1230. I agree: Once your application has been registered on our housing list, we will send you a registration letter. • That you may process my/our personal data as in the aforementioned statement, which may include The registration letter will tell you your application number and how many points you have been contacting and sharing information with my/our current/previous landlords, my/our doctor, hospital awarded. consultant, health visitor, social work and health professionals, police and criminal justice or any other relevant person, if more information is needed in connection with my/our housing application Your application will be treated in confidence and in compliance with the Data Protection Act • That I/we will inform Homes4D&G of any change in my/our circumstances 2018 • That all information given by me/us to Homes4D&G is true and accurate • That if I/we are given a tenancy because I/we have supplied false information or I/we have held back any information that the landlord will take action to end the tenancy. What we will do with your information/personal data: • If I/we accept a property offered through Homes4D&G including mutual exchange that my/our application will be cancelled and that I/we will have to submit a fresh application if I/we wish to move Homes4D&G is a partnership involving Dumfries & Galloway Council and Registered Social again. Landlords: Dumfries and Galloway Housing Partnership, Home Group, Irvine Housing Association and Cunninghame Housing Association. Applicant’s Signature Date We will use the information you provide to Homes4D&G to process your application for housing. The information will be shared with the Homes4D&G partners. Joint Applicant’s Signature Date

With your permission we may contact others to get more information to help us process your Please note that if this declaration is not completed then we will be unable to process application. This may include: your application • Your current or previous landlords • Medical and Health professionals Application deferral • Police • Others with relevant information If you do not wish to be considered for a property in the foreseeable future, you can choose to defer (postpone) your application This information will be used to assess your application in accordance with the Homes 4 D&G Do you wish your application to be deferred? Yes No Common Allocation Policy and match your requirements and preferences against any available properties. If yes, please give your reasons and provide the date you wish your application to be deferred until:

The information will also be used for statistical and monitoring purposes. Reason:

We will not disclose your personal data beyond the Homes4D&G partners except where required to Please defer my application until Month: Year: do so by law unless you have given your permission to do so.

Do you require the services of an interpreter? Yes No If yes, please provide details

22 3 Declaration Guidance Notes Before completing this form please read through the following statements and sign at the Please print clearly and answer all the questions as fully as possible. If you need support to complete bottom to show that you understand and agree with them. this form, please call us on 0300 123 1230. I agree: Once your application has been registered on our housing list, we will send you a registration letter. • That you may process my/our personal data as in the aforementioned statement, which may include The registration letter will tell you your application number and how many points you have been contacting and sharing information with my/our current/previous landlords, my/our doctor, hospital awarded. consultant, health visitor, social work and health professionals, police and criminal justice or any other relevant person, if more information is needed in connection with my/our housing application Your application will be treated in confidence and in compliance with the Data Protection Act • That I/we will inform Homes4D&G of any change in my/our circumstances 2018 • That all information given by me/us to Homes4D&G is true and accurate • That if I/we are given a tenancy because I/we have supplied false information or I/we have held back any information that the landlord will take action to end the tenancy. What we will do with your information/personal data: • If I/we accept a property offered through Homes4D&G including mutual exchange that my/our application will be cancelled and that I/we will have to submit a fresh application if I/we wish to move Homes4D&G is a partnership involving Dumfries & Galloway Council and Registered Social again. Landlords: Dumfries and Galloway Housing Partnership, Home Group, Irvine Housing Association and Cunninghame Housing Association. Applicant’s Signature Date We will use the information you provide to Homes4D&G to process your application for housing. The information will be shared with the Homes4D&G partners. Joint Applicant’s Signature Date

The information will also be used for statistical and monitoring purposes. Reason:

Do you require the services of an interpreter? Yes No If yes, please provide details

2 3 3 Section 1 – Name and address Correspondence Address If you would like us to write to you at another address, or if you have no permanent address, please Main Applicant Joint Applicant provide details:

Title Title

Surname Surname

First name(s) First name(s) Section 2 – Your present accommodation

Date of birth Date of birth When did you move into your present address? Main applicant Joint applicant Gender Gender Date Date Preferred Preferred pronoun pronoun Please tick the box that best describes your current accommodation Are you? (Please tick) √ Name you would Name you would like to be called like to be called A tenant of DGHP Living with family A tenant of Home Group Living with non-family House number House number A tenant of Irvine Housing Association A lodger A tenant of Cunninghame HA Street name Street name A tenant of a housing association or Staying in supported accommodation co-operative out with D&G Town Town A tenant of another housing association or Staying in homeless bed and breakfast co-operative within D&G accommodation Postcode Postcode No permanent accommodation (NFA) / Staying in homeless furnished Living rough accommodation Telephone Mobile Telephone Mobile A shared owner of a house with a housing In HM Forces tied accommodation Home Home association Work Work A tenant of a private landlord In residential care Email address Email address A tenant of tied accommodation In prison An owner occupier In hospital Marital status Marital status Staying in a mobile home or caravan If none of the above apply, give details here Nat. Ins. number Nat. Ins. number First language First language If none of the above apply, please give details here Nationality Nationality Relationship to main applicant

Known by any other name Who is the landlord of your current address? (where applicable) Have you or any joint applicant ever been known by any other name? Yes No Name and address of landlord If yes, please provide details:

Main Applicant Joint Applicant Names Dates Names Dates Contact telephone number

44 5 Section 1 – Name and address Correspondence Address If you would like us to write to you at another address, or if you have no permanent address, please Main Applicant Joint Applicant provide details:

Title Title

Surname Surname

First name(s) First name(s) Section 2 – Your present accommodation

Date of birth Date of birth When did you move into your present address? Main applicant Joint applicant Gender Gender Date Date Preferred Preferred pronoun pronoun Please tick the box that best describes your current accommodation Are you? (Please tick) √ Name you would Name you would like to be called like to be called A tenant of DGHP Living with family A tenant of Home Group Living with non-family House number House number A tenant of Irvine Housing Association A lodger A tenant of Cunninghame HA Street name Street name A tenant of a housing association or Staying in supported accommodation co-operative out with D&G Town Town A tenant of another housing association or Staying in homeless bed and breakfast co-operative within D&G accommodation Postcode Postcode No permanent accommodation (NFA) / Staying in homeless furnished Living rough accommodation Telephone Mobile Telephone Mobile A shared owner of a house with a housing In HM Forces tied accommodation Home Home association Work Work A tenant of a private landlord In residential care Email address Email address A tenant of tied accommodation In prison An owner occupier In hospital Marital status Marital status Staying in a mobile home or caravan OtherIf none of the above apply, give details here Nat. Ins. number Nat. Ins. number First language First language If none of the above apply, pleaseplease givegive detailsdetails herehere Nationality Nationality Relationship to main applicant

Known by any other name Who is the landlord of your current address? (where (where applicable) applicable) Have you or any joint applicant ever been known by any other name? Yes No Name and address of landlord If yes, please provide details:

Main Applicant Joint Applicant Names Dates Names Dates Contact telephone number Contact telephone number Email address

4 5 5 Email address

Please provide the date that you are required to leave your Date accommodation Please provide the date that you are required to leave your Date accommodation Tied tenants only What type of property do you live in just now? TiedPlease tenants provide only the date you will be expected to leave your accommodation Date Four in a block flat – ground floor Bedsit - bungalow Please provide the date you will be expected to leave your Four in a block flat – upper floor Bedsit – ground floor accommodationHave you been given written notice to leave? If you have answered Date Flat – lower ground floor Bedsit – upper floor ‘Yes’ please provide a copy of the letter/documentation. Yes No Flat – ground floor Residential development for older people Have you been given written notice to leave? If you have answered Has a court order for possession been granted? If you have answered Yes No Flat – 1st floor Other supported accommodation ‘Yes’ please provide a copy of the letter/documentation. ‘Yes’ please provide a copy of the documentation. Yes No Flat – 2nd floor Amenity Has a court order for possession been granted? If you have answered Flat – 3rd floor Sheltered accommodation ‘Yes’ please provide a copy of the documentation. Yes No Flat – 4th floor or above Hostel Private tenants only Maisonette – ground floor Hotel PrivateDo you havetenants a written only tenancy agreement? Yes No Maisonette – upper floor Bed and breakfast Do you have a written tenancy agreement? DateYes No House – detached (with internal stairs) Local authority residential care If you have been asked to leave your current accommodation. What date are you expected to leave? House – semi-detached (with internal stairs) Hospital If you have been asked to leave your current accommodation. Date House – terraced (with internal stairs) Nursing home What date are you expected to leave? Bungalow – detached Caravan Have you been given written notice to leave? If you have answered ‘Yes’ please provide a copy of the order along with Yes No Bungalow – semi-detached Prison aHave copy you of yourbeen tenancy given written agreement notice. to leave? Bungalow - terraced Student accommodation If you have answered ‘Yes’ please provide a copy of the order along with Yes No Has a court order for possession been granted? Other (please specify) a copy of your tenancy agreement. Yes No If you have answered ‘Yes’ please provide a copy of the order. Has a court order for possession been granted? Yes No If you have answered ‘Yes’ please provide a copy of the order. How many bedrooms does the property have? How many bedrooms do you have for exclusive use of you and any people who will be moving with you? TOLERABLE STANDARD The tolerable standard is a minimum repair standard set by law which sets out the minimum standard TOLERABLE STANDARD Do you share a bathroom or kitchen or living room (or all 3 rooms) with needed to make a house fit to live in. Please advise if your current home: Yes No The tolerable standard is a minimum repair standard set by law which sets out the minimum standard people who will NOT be moving with you? Is structurally stable Yes No needed to make a house fit to live in. Please advise if your current home: Does the property you live in have a shared entrance? Yes No Is structurallysubstantially stable free from rising or penetrating damp Yes No Does the property you live in have its own garden? Yes No IsHas substantially satisfactory free provision from rising for natural or penetrating and artificial damp lighting Yes No Yes No Has satisfactory provision for naturalventilation and in artificial the kitchen lighting and bathroom e.g. Yes No windows or extractor fan H.M. Forces personnel only Has satisfactory provision for ventilation in the kitchen and bathroom e.g. Yes No Has a sink provided with an adequate supply of hot and cold water within the Yes No windows or extractor fan Do you live in barracks? Yes No house Has a sink provided with an adequate supply of hot and cold water within the Yes No Or other HM Forces tied tenancy Yes No Yes No houseHas a toilet, fixed bath or shower and wash-hand basin within the house Please state your discharge from HM Forces Date Yes No Has asatisfactory toilet, fixed facilities bath or forshower the cooking and wash-hand of food within basin the within house the house Yes No Has satisfactory access to all external doors and any outbuildings Yes No Are you being discharged due to injuries or disabilities sustained while Has satisfactory facilities for the cooking of food within the house Yes No Has an effective system for the drainage and disposal of foul and surface water Yes No serving in Armed Forces? Has satisfactory access to all external doors and any outbuildings Yes No Has adequate and safe to use electrics Yes No Are there other circumstances that are required to be taken into Has an effective system for the drainage and disposal of foul and surface water Yes No consideration that relates to your discharge from HM Forces? Has adequate and safe to use electrics Yes No Please detail: If you have answered No to any of the above questions please provide details below 7 6 7

Please provide the date that you are required to leave your Date accommodation What type of heating does the property have? Is your present accommodation the subject of a closing order due to its Yes No Tied tenants only dangerous condition? Please6 provide the date you will be expected to leave your accommodation Date Section 3 – Reasons for applying Have you been given written notice to leave? If you have answered ‘Yes’ please provide a copy of the letter/documentation. Yes No What is your main reason for applying for housing? Has a court order for possession been granted? If you have answered Need a smaller property Discharge from armed forces ‘Yes’ please provide a copy of the documentation. Yes No Need a bigger property Fleeing antisocial behaviour Want to move to another area Fleeing domestic violence End of lease Homelessness Private tenants only Eviction order Gender/sexuality related Do you have a written tenancy agreement? Yes No abuse Losing tied accommodation To provide/receive support If you have been asked to leave your current accommodation. Date Leaving family home To be near employment What date are you expected to leave? Poor condition of current property Being released from prison Have you been given written notice to leave? Unable to maintain garden Pregnancy If you have answered ‘Yes’ please provide a copy of the order along with Yes No Want a property with a garden Can’t afford present housing rental a copy of your tenancy agreement. Medical reasons Heating/energy costs Remoteness Relationship breakdown Has a court order for possession been granted? Yes No Regeneration If you have answered ‘Yes’ please provide a copy of the order. Other (please state)

Pregnancy TOLERABLE STANDARD Are you or anyone who will be housed with you pregnant? Yes No The tolerable standard is a minimum repair standard set by law which sets out the minimum standard needed to make a house fit to live in. Please advise if your current home: Name of person who is pregnant Is structurally stable Yes No Date the child is due Is substantially free from rising or penetrating damp Yes No Has satisfactory provision for natural and artificial lighting Yes No Medical Has satisfactory provision for ventilation in the kitchen and bathroom e.g. Yes No If you are applying on medical grounds, you will need to complete a medical application form to allow windows or extractor fan us to carry out an assessment, to determine if you qualify for medical points. Has a sink provided with an adequate supply of hot and cold water within the Yes No Have you completed a medical form? Yes No house Has a toilet, fixed bath or shower and wash-hand basin within the house Yes No Help to live independently Has satisfactory facilities for the cooking of food within the house Yes No If you need to move home to receive or provide help to live independently please provide details Yes No Has satisfactory access to all external doors and any outbuildings below. We may write to you or the person receiving or providing help to confirm the information Has an effective system for the drainage and disposal of foul and surface water Yes No provided. Has adequate and safe to use electrics Yes No

8 7 Email address

Please provide the date that you are required to leave your Date accommodation Please provide the date that you are required to leave your Date accommodation Tied tenants only What type of property do you live in just now? TiedPlease tenants provide only the date you will be expected to leave your accommodation Date Four in a block flat – ground floor Bedsit - bungalow Please provide the date you will be expected to leave your Four in a block flat – upper floor Bedsit – ground floor accommodationHave you been given written notice to leave? If you have answered Date Flat – lower ground floor Bedsit – upper floor ‘Yes’ please provide a copy of the letter/documentation. Yes No Flat – ground floor Residential development for older people Have you been given written notice to leave? If you have answered Has a court order for possession been granted? If you have answered Yes No Flat – 1st floor Other supported accommodation ‘Yes’ please provide a copy of the letter/documentation. ‘Yes’ please provide a copy of the documentation. Yes No Flat – 2nd floor Amenity Has a court order for possession been granted? If you have answered Flat – 3rd floor Sheltered accommodation ‘Yes’ please provide a copy of the documentation. Yes No Flat – 4th floor or above Hostel Private tenants only Maisonette – ground floor Hotel PrivateDo you havetenants a written only tenancy agreement? Yes No Maisonette – upper floor Bed and breakfast Do you have a written tenancy agreement? YesDate No House – detached (with internal stairs) Local authority residential care If you have been asked to leave your current accommodation. What date are you expected to leave? House – semi-detached (with internal stairs) Hospital If you have been asked to leave your current accommodation. Date House – terraced (with internal stairs) Nursing home What date are you expected to leave? Bungalow – detached Caravan Have you been given written notice to leave? If you have answered ‘Yes’ please provide a copy of the order along with Yes No Bungalow – semi-detached Prison aHave copy you of yourbeen tenancy given written agreement notice. to leave? Bungalow - terraced Student accommodation If you have answered ‘Yes’ please provide a copy of the order along with Yes No Has a court order for possession been granted? Other (please specify) a copy of your tenancy agreement. Yes No If you have answered ‘Yes’ please provide a copy of the order. Has a court order for possession been granted? Yes No If you have answered ‘Yes’ please provide a copy of the order. How many bedrooms does the property have? How many bedrooms do you have for exclusive use of you and any people who will be moving with you? TOLERABLE STANDARD The tolerable standard is a minimum repair standard set by law which sets out the minimum standard TOLERABLE STANDARD Do you share a bathroom or kitchen or living room (or all 3 rooms) with needed to make a house fit to live in. Please advise if your current home: Yes No The tolerable standard is a minimum repair standard set by law which sets out the minimum standard people who will NOT be moving with you? Is structurally stable Yes No needed to make a house fit to live in. Please advise if your current home: Does the property you live in have a shared entrance? Yes No Is structurallysubstantially stable free from rising or penetrating damp Yes No Does the property you live in have its own garden? Yes No IsHas substantially satisfactory free provision from rising for natural or penetrating and artificial damp lighting Yes No Yes No Has satisfactory provision for naturalventilation and in artificial the kitchen lighting and bathroom e.g. Yes No windows or extractor fan H.M. Forces personnel only Has satisfactory provision for ventilation in the kitchen and bathroom e.g. Yes No Has a sink provided with an adequate supply of hot and cold water within the Yes No windows or extractor fan Do you live in barracks? Yes No house Has a sink provided with an adequate supply of hot and cold water within the Yes No Or other HM Forces tied tenancy Yes No Yes No houseHas a toilet, fixed bath or shower and wash-hand basin within the house Please state your discharge from HM Forces Date Yes No Has asatisfactory toilet, fixed facilities bath or forshower the cooking and wash-hand of food within basin the within house the house Yes No Has satisfactory access to all external doors and any outbuildings Yes No Are you being discharged due to injuries or disabilities sustained while Has satisfactory facilities for the cooking of food within the house Yes No Has an effective system for the drainage and disposal of foul and surface water Yes No serving in Armed Forces? Has satisfactory access to all external doors and any outbuildings Yes No Has adequate and safe to use electrics Yes No Are there other circumstances that are required to be taken into Has an effective system for the drainage and disposal of foul and surface water Yes No consideration that relates to your discharge from HM Forces? Has adequate and safe to use electrics Yes No Please detail: If you have answered No to any of the above questions please provide details below 7 6 7

Please provide the date that you are required to leave your Date accommodation What type of heating does the property have? Is your present accommodation the subject of a closing order due to its Yes No Tied tenants only dangerous condition? Please provide the date you will be expected to leave your 7 accommodation Date Section 3 – Reasons for applying Have you been given written notice to leave? If you have answered ‘Yes’ please provide a copy of the letter/documentation. Yes No What is your main reason for applying for housing? Has a court order for possession been granted? If you have answered Need a smaller property Discharge from armed forces ‘Yes’ please provide a copy of the documentation. Yes No Need a bigger property Fleeing antisocial behaviour Want to move to another area Fleeing domestic violence End of lease Homelessness Private tenants only Eviction order Gender/sexuality related Do you have a written tenancy agreement? Yes No abuse Losing tied accommodation To provide/receive support If you have been asked to leave your current accommodation. Date Leaving family home To be near employment What date are you expected to leave? Poor condition of current property Being released from prison Have you been given written notice to leave? Unable to maintain garden Pregnancy If you have answered ‘Yes’ please provide a copy of the order along with Yes No Want a property with a garden Can’t afford present housing rental a copy of your tenancy agreement. Medical reasons Heating/energy costs Remoteness Relationship breakdown Has a court order for possession been granted? Yes No Regeneration If you have answered ‘Yes’ please provide a copy of the order. Other (please state)

8 7 If you have answered No to any of the above questions please provide details below If you have answered No to any of the above questions please provide details below

What type of heating does the property have? IsWhat your type present of heating accommodation does the property the subject have? of a closing order due to its Yes No dangerousIs your present condition? accommodation the subject of a closing order due to its Yes No dangerous condition?

Section 3 – Reasons for applying Section 3 – Reasons for applying Section 4 – Supervision orders What is your main reason for applying for housing? WhatNeed is your a smaller main reason property for applying for housing? Discharge from armed forces Are you or any joint applicant or anyone to be rehoused with you Yes No Need a biggersmaller property property FleeingDischarge antisocial from armed behaviour forces required to register with the police under the Sex Offenders Act 1997? WantNeed toa biggermove toproperty another area Fleeing antisocialdomestic violencebehaviour If yes, please give details: EndWant of to lease move to another area HomelessnessFleeing domestic violence EvictionEnd of lease order Gender/sexualityHomelessness related Eviction order abuseGender/sexuality related abuse Losing tied accommodation Toabuse provide/receive support LeavingLosing tied family accommodation home To beprovide/receive near employment support Section 5 – Antisocial behaviour PoorLeaving condition family homeof current property BeingTo be releasednear employment from prison Are you or anyone who is moving with you the subject of an antisocial Yes No UnablePoor condition to maintain of current garden property PregnancyBeing released from prison behaviour order (ASBO) or has received a final warning either from the WantUnable a propertyto maintain with garden a garden Can’tPregnancy afford present housing rental Police, local authority or your landlord for antisocial behaviour? MedicalWant a propertyreasons with a garden Heating/energyCan’t afford present costs housing rental If yes, please provide details including dates: Date RemotenessMedical reasons RelationshipHeating/energy breakdown costs RegenerationRemoteness Relationship breakdown OtherRegeneration (please state) Other (please state)

Pregnancy ArePregnancy you or anyone who will be housed with you pregnant? Yes No Are you or anyone who will be housed with you pregnant? Yes No Name of person who is pregnant Section 6 – Harassment DateName the of personchild is whodue is pregnant Date the child is due Are any members of your household experiencing disturbance or Yes No harassment? Medical If you have answered ‘Yes’ please tick any of the following that apply IfMedical you are applying on medical grounds, you will need to complete a medical application form to allow usIf you to carry are applying out an assessment, on medical grounds, to determine you willif you need qualify to complete for medical a medical points. application form to allow Problems with neighbours Racial harassment Serious antisocial behaviour Haveus to carryyou completed out an assessment, a medical toform? determine if you qualify for medical points.Yes No Please explain in more detail Have you completed a medical form? Yes No Help to live independently IfHelp you to need live independentlyto move home to receive or provide help to live independently please provide details below.If you need We mayto move write home to you to orreceive the person or provide receiving help or to providing live independently help to confirm please the provide information details provided.below. We may write to you or the person receiving or providing help to confirm the information provided.

9 8 8 Have you reported any of the incidents? Yes No If you have answered ‘Yes’ who have you reported the incidents to? The Police D&G Council ASB Your landlord or housing Team office Other (please state)

Section 4 – Supervision orders 8 Section 7 – Your household Are you or any joint applicant or anyone to be rehoused with you Yes No required to register with the police under the Sex Offenders Act 1997? Please give details of EVERYONE living in your current accommodation. You should If yes, please give details: include all the people who live with you at present and all the people who will live with you when you are re-housed, including any children who stay with you overnight under residence and contact (access) arrangements.

Name Relationship Date of National Tick To be **Child Section 5 – Antisocial behaviour to you birth Insurance (√) if rehoused Access Number (if living with you Are you or anyone who is moving with you the subject of an antisocial Yes No over 16 away (Yes/No) behaviour order (ASBO) or has received a final warning either from the years) * Police, local authority or your landlord for antisocial behaviour? If yes, please provide details including dates: Date Gen der

Section 6 – Harassment

Are any members of your household experiencing disturbance or Yes No harassment? If you have answered ‘Yes’ please tick any of the following that apply Problems with neighbours Racial harassment Serious antisocial behaviour Please explain in more detail

*Living Away If you have ticked living away please give their address and why they do not live with you.

Address:

9 10 If you have answered No to any of the above questions please provide details below If you have answered No to any of the above questions please provide details below

Section 3 – Reasons for applying Section 3 – Reasons for applying Section 4 – Supervision orders What is your main reason for applying for housing? WhatNeed is your a smaller main reason property for applying for housing? Discharge from armed forces Are you or any joint applicant or anyone to be rehoused with you Yes No Need a biggersmaller property property FleeingDischarge antisocial from armed behaviour forces required to register with the police under the Sex Offenders Act 1997? WantNeed toa biggermove toproperty another area Fleeing antisocialdomestic violencebehaviour If yes, please give details: EndWant of to lease move to another area HomelessnessFleeing domestic violence EvictionEnd of lease order Gender/sexualityHomelessness related Eviction order abuseGender/sexuality related Losing tied accommodation Toabuse provide/receive support LeavingLosing tied family accommodation home To beprovide/receive near employment support Section 5 – Antisocial behaviour PoorLeaving condition family homeof current property BeingTo be releasednear employment from prison Are you or anyone who is moving with you the subject of an antisocial Yes No UnablePoor condition to maintain of current garden property PregnancyBeing released from prison behaviour order (ASBO) or has received a final warning either from the WantUnable a propertyto maintain with garden a garden Can’tPregnancy afford present housing rental Police, local authority or your landlord for antisocial behaviour? MedicalWant a propertyreasons with a garden Heating/energyCan’t afford present costs housing rental If yes, please provide details including dates: Date RemotenessMedical reasons RelationshipHeating/energy breakdown costs RegenerationRemoteness Relationship breakdown OtherRegeneration (please state) Other (please state)

Section 4 – Supervision orders Section 7 – Your household 9 Are you or any joint applicant or anyone to be rehoused with you Yes No required to register with the police under the Sex Offenders Act 1997? Please give details of EVERYONE living in your current accommodation. You should If yes, please give details: include all the people who live with you at present and all the people who will live with you when you are re-housed, including any children who stay with you overnight under residence and contact (access) arrangements.

Section 6 – Harassment

*Living Away If you have ticked living away please give their address and why they do not live with you.

Address:

9 10 Reason:

Have you reported any of the incidents? Yes No IfHave you youhave reported answered any ‘Yes’ of the who incidents? have you reported the incidents to? Yes No **Child Access If youThe have Police answered ‘Yes’ who have youD&G reported Council the incidentsASB to? Your landlord or housing If you have residence and contact (access) with children, how many nights per week do The Police D>eam Council ASB Youroffice landlord or housing they stay with you? Other (please state) Team office Please give the main place of residence of the children. Other (please state) Address:

Section 7 – Your household Section 8 – Your housing requirements Section 7 – Your household Please give details of EVERYONE living in your current accommodation. You should Please tick which Homes 4 D&G landlords you want to be considered for. Pleaseinclude give all the details people of EVERYONEwho live with living you atin presentyour current and all accommodation. the people who You will shouldlive with You may tick as many as you wish. If you do not indicate your landlord preferences we will assume includeyou when all you the arepeople re-housed, who live including with you anyat present children and who all staythe peoplewith you who overnight will live underwith that you want to be housed by any of the partner landlords. youresidence when youand arecontact re-housed, (access) including arrangements. any children who stay with you overnight under Dumfries & Galloway Housing Partnership Cunninghame Housing Association residence and contact (access) arrangements. NameName RelationshipRelationship GenderDateDate of NationalNational Tick To be **Child**Child Name Relationshiptoto you you Datebirthof birthof NationalInsuranceInsurance Tick(√)(✓) if Torehoused be Access**Child to you birth InsuranceNumberNumber (if (√)living if rehousedwith you Access Home Group Irvine Housing Association Numberover(if over 16 (if livingawayaway* with(Yes/No) you overyears) 16 away* (Yes/No) 16 years) N.B. Please note that you will only be matched for accommodation that your chosen landlord has in years) * your areas of choice

Gen Bedroom requirements Gender Homes4D&G will only register your application for the size of accommodation that you qualify der for in accordance with the Common Allocation Policy. We work out the number of bedrooms you require, based on who will be living permanently in the household.  One bedroom for single adults  One bedroom for couples/partners  One bedroom for two children of different sex up to 8 years old  One bedroom for two children of the same sex up to 12 years old  One bedroom for each child of 12 years or over  No more than two people should have to share a bedroom The table below shows the number of bedrooms you can have depending on the size of your household. Please note that you can only register for one size of property.

Number of bedrooms you can be considered for Household size Bed-sit One Two Three Four Five + Single Person ● ● *Living Away If*Living you have Away ticked living away please give their address and why they do not live with you. Couple ● ● If you have ticked living away please give their address and why they do not live with you. Couple or single adult and 1 other person ●

Address: Couple or single adult with 2 children both ● Address: under 8 Couple or single adult with 2 same ● 11 10 gender children both under 12 10 Couple or single adult with 2 opposite ● gender children and 1 is aged 8 or over Reason: Couple or single adult with 3 mixed ● gender children all under 8 Couple or single adult with 3 same ● gender children all under 12 **Child Access Couple or single adult with 3 mixed ● If you have residence and contact (access) with children, how many nights per week do gender children and 1 is over 8 they stay with you? Couple or single adult with 3 mixed ● ● Please give the main place of residence of the children. gender children and 1 is over 12 Couple or single adult with 3 mixed ● ● Address: gender children and 2 are over 8 Couple or single adult with 3 children all ● over 12 Any larger household ● ●

What size of house would you like? 10

Areas of choice and property types Section 8 – Your housing requirements You can choose as many areas in Dumfries and Galloway as you would want to live in. Please tick which Homes 4 D&G landlords you want to be considered for. Applicants may be offered the first available property from any of their chosen areas. You You may tick as many as you wish. If you do not indicate your landlord preferences we will assume should only choose areas where you would be happy to accept an offer of housing. that you want to be housed by any of the partner landlords. Dumfries & Galloway Housing Partnership Cunninghame Housing Association Please note that not all landlords have houses in these areas. We can only offer you housing in areas selected below and for landlords you have chosen.

East Home Group Irvine Housing Association

Tick Tick Tick Area/Town Area/Town Area/Town N.B. Please note that you will only be matched for accommodation that your chosen landlord has in (√) (√) (√) your areas of choice Annan - Galabank D19A Eastriggs D14A Lockerbie-Hillview D24A

Lockerbie-King Edward Annan - Kimmeter D28A Ecclefechan D15A D29A Bedroom requirements Park Homes4D&G will only register your application for the size of accommodation that you qualify Annan - Newington D39A Eskdalemuir D16A Lockerbie-Kintail Park D30A for in accordance with the Common Allocation Policy. Annan - Town centre D01A Evertown D17A Lockerbie-Rosebank D42A We work out the number of bedrooms you require, based on who will be living permanently in the household. Annan - Welldale D49A Gair D18A Lockerbie-Town Centre D34A  One bedroom for single adults Bankshill D02A Gretna D20A Middlebie D35A  One bedroom for couples/partners  One bedroom for two children of different sex up to 8 years old Beattock D03A Gretna Green D21A Millhousebridge D36A  One bedroom for two children of the same sex up to 12 years old Boreland D04A Harelaw D22A Moffat D25A  One bedroom for each child of 12 years or over  No more than two people should have to share a bedroom Brydekirk D05A Hightae D23A Newbie D38A The table below shows the number of bedrooms you can have depending on the size of your household. Canonbie D06A Johnstonebridge D27A Rigg D41A Please note that you can only register for one size of property. Carrutherstown D07A Kirkpatrick Fleming D31A Rowanburn D43A Number of bedrooms you can be considered for Household size Bed-sit One Two Three Four Five + Chapelknowe D09A Kirtlebridge D32A Siddaldbie D44A Single Person ● ● Dornock D12A Langholm D08A Springfield D45A

Couple ● ● Eaglesfield D13A Lochmaben D33A Templand D46A Couple or single adult and 1 other person ● 12 Couple or single adult with 2 children both ● under 8 11 Reason:

Section 7 – Your household Section 8 – Your housing requirements Section 7 – Your household Please give details of EVERYONE living in your current accommodation. You should Please tick which Homes 4 D&G landlords you want to be considered for. Pleaseinclude give all the details people of EVERYONEwho live with living you atin presentyour current and all accommodation. the people who You will shouldlive with You may tick as many as you wish. If If you you do do not not indicate indicate your your landlord landlord preferences preferences we we will will assume assume includeyou when all you the arepeople re-housed, who live including with you anyat present children and who all staythe peoplewith you who overnight will live underwith thatthat youyou wantwant toto bebe housedhoused byby anyany ofof thethe partnerpartner landlords.landlords. youresidence when youand arecontact re-housed, (access) including arrangements. any children who stay with you overnight under Dumfries & Galloway Housing Partnership Cunninghame Housing Association residence and contact (access) arrangements. Dumfries & Galloway Housing Partnership Cunninghame Housing Association Name Relationship Date of National Tick To be **Child Name Relationshipto you Datebirth of NationalInsurance Tick(√) if Torehoused be **ChildAccess Home Group Irvine Housing Association to you birth InsuranceNumber (if (√)living if rehousedwith you Access Home Group Irvine Housing Association Numberover 16 (if livingaway with(Yes/No) you N.B. Please note that you will only be matched for accommodation that your chosen landlord has in overyears) 16 away* (Yes/No) N.B.your Pleaseareas of note choice that you will only be matched for accommodation that your chosen landlord has in years) * your areas of choice

What size of house would you like? 11

East Home Group Irvine Housing Association

Couple ● ● Eaglesfield D13A Lochmaben D33A Templand D46A Couple or single adult and 1 other person ● 12 Couple or single adult with 2 children both ● under 8 11 Couple or single adult with 2 same ● gender children both under 12 Couple or single adult with 2 opposite ● gender children and 1 is aged 8 or over Couple or single adult with 3 mixed ● gender children all under 8 Couple or single adult with 3 same ● gender children all under 12 Couple or single adult with 3 mixed ● gender children and 1 is over 8 Couple or single adult with 3 mixed ● ● gender children and 1 is over 12 Couple or single adult with 3 mixed ● ● gender children and 2 are over 8 Couple or single adult with 3 children all ● over 12 Any larger household ● ●

What size of house would you like?

Central Areas of choice and property types

Tick Tick Tick Area/Town Area/Town Area/Town You can choose as many areas in Dumfries and Galloway as you would want to live in. (√) (√) (√) Applicants may be offered the first available property from any of their chosen areas. You Dumfries - The Ae D01N D56N Mid Nithsdale-Penpont D44N should only choose areas where you would be happy to accept an offer of housing. Meadows Amisfield D02N Dumfries-Town Centre D17N Mid Nithsdale-Thornhill D52N Please note that not all landlords have houses in these areas. We can only offer you housing in areas selected below and for landlords you have chosen. Bankend D05N Dumfries-Troqueer D54N Mouswald D38N Beeswing D06N Dunscore D18N Nethermill D39N

East Cargenbridge D10N Glencaple D21N New Abbey D40N

Collin D14N Holywood D22N Parkgate D43N Tick Tick Tick Area/Town Area/Town Area/Town (√) (√) (√) Dumfries-Balmoral D04N Kelton D26N Prestonmill D45N Annan - Galabank D19A Eastriggs D14A Lockerbie-Hillview D24A Dumfries-Broomlands D07N Kingholm Quay D27N Shawhead D47N Lockerbie-King Edward Annan - Kimmeter D28A Ecclefechan D15A D29A Park Dumfries-Cresswell D16N Kirkmahoe D29N Shieldhill D48N Annan - Newington D39A Eskdalemuir D16A Lockerbie-Kintail Park D30A Dumfries-Georgetown D20N Kirkton D30N Terregles D51N

Annan - Town centre D01A Evertown D17A Lockerbie-Rosebank D42A Dumfries-Janefield D23N Locharbriggs D33N Torthorwald D53N Upper Nithsdale- Annan - Welldale D49A Gair D18A Lockerbie-Town Centre D34A Dumfries-Larchfield D31N Marchmount D35N D15N Crawick Upper Nithsdale- Bankshill D02A Gretna D20A Middlebie D35A Dumfries-Lincluden D32N Mid Nithsdale-Auldgirth D03N D25N Kelloholm Upper Nithsdale- Beattock D03A Gretna Green D21A Millhousebridge D36A Dumfries-Lochside D34N Mid Nithsdale-Burnhead D08N D28N Kirkconnel Upper Nithsdale- Boreland D04A Harelaw D22A Moffat D25A Dumfries-Millburn D36N Mid Nithsdale-Cample D09N D46N Sanquhar Mid Nithsdale- Brydekirk D05A Hightae D23A Newbie D38A Dumfries-Newbridge D58N D11N Wallaceton D55N Carronbridge

Canonbie D06A Johnstonebridge D27A Rigg D41A Dumfries-Nithside D41N Mid Nithsdale-Closeburn D13N

Carrutherstown D07A Kirkpatrick Fleming D31A Rowanburn D43A Dumfries-Summerhill D49N Mid Nithsdale-Moniaive D37N

Chapelknowe D09A Kirtlebridge D32A Siddaldbie D44A Dumfries-Summerville D50N Mid Nithsdale-Park D42N

Dornock D12A Langholm D08A Springfield D45A

Eaglesfield D13A Lochmaben D33A Templand D46A 13 12

12 Couple or single adult with 2 same ● gender children both under 12 Couple or single adult with 2 opposite ● gender children and 1 is aged 8 or over Couple or single adult with 3 mixed ● gender children all under 8 Couple or single adult with 3 same ● gender children all under 12 Couple or single adult with 3 mixed ● gender children and 1 is over 8 Couple or single adult with 3 mixed ● ● gender children and 1 is over 12 Couple or single adult with 3 mixed ● ● gender children and 2 are over 8 Couple or single adult with 3 children all ● over 12 Any larger household ● ●

What size of house would you like?

Central Areas of choice and property types

East Cargenbridge D10N Glencaple D21N New Abbey D40N

Canonbie D06A Johnstonebridge D27A Rigg D41A Dumfries-Nithside D41N Mid Nithsdale-Closeburn D13N

Carrutherstown D07A Kirkpatrick Fleming D31A Rowanburn D43A Dumfries-Summerhill D49N Mid Nithsdale-Moniaive D37N

Chapelknowe D09A Kirtlebridge D32A Siddaldbie D44A Dumfries-Summerville D50N Mid Nithsdale-Park D42N

Dornock D12A Langholm D08A Springfield D45A

Eaglesfield D13A Lochmaben D33A Templand D46A 13 12

13 West (Stewartry) Exceptions

Please tell us about the areas that you would NOT consider an offer of housing. Tick Tick Tick Area/Town Area/Town Area/Town (√) (√) (√) Please remember that the more restrictive you are in your choices, the longer you may have Auchencairn D01S Dalry D11S Lochfoot D20S to wait. Balmaclellan D02S Dundrennan D12S New Galloway D21S Street name Town or village the street is located in

Borgue D03S Gatehouse of Fleet D13S Old Bridge of Urr D22S 1. 2. Bridge of Dee D04S Gelston D14S Palnackie D23S 3. Carsphairn D05S Glenlochar D15S Portling D24S 4. Castle Douglas D06S Haugh of Urr D16S Rhonehouse D25S 5. Crocketford D08S Kirkcudbright D17S Ringford D26S 6.

Crossmichael D09S Kirkgunzeon D18S Springholm D27S 7.

Dalbeattie D10S Laurieston D19S Twynholm D28S 8. 9. 10.

West (Wigtown)

Tick Tick Tick Please tell us what type of property you would like. (√) Area/Town (√) Area/Town (√) Area/Town You may tick as many boxes as you wish. Cairnryan D02W Kirkinner D14W Sandhead D27W

Carty D03W Leswalt D15W Sorbie D28W For a description of our property types, please refer to the application guidance notes. This will explain eligibility for sheltered and amenity housing. Castle Kennedy D04W Lochans D16W Stoneykirk D29W Four in a block flat – ground floor House with internal stairs Creetown D05W Minnigaff D17W Stranraer-Belmont D30W Four in a block flat – upper floor Bungalow Culquhirk D06W Mochrum D18W Stranraer-Dicks Hill D31W Flat – ground floor Bedsit bungalow Drummore D07W Mochrum Park D19W Stranraer-East End D32W Flat – 1st floor Bedsit – ground floor Dunragit D08W Monreith D20W Stranraer-Ochtrelure D33W Flat – 2nd floor Bedsit – 1st floor Garlieston D09W New Luce D21W Stranraer-Sheuchan D34W Flat – 3rd floor Bedsit – 2nd floor Glenluce D10W Newton Stewart D22W Stranraer-Central D35W Flat – 4th floor or above Sheltered housing Glenstockadale D40W Palnure D23W Stranraer-West End D36W Maisonette – ground floor Amenity housing Isle of Whithorn D11W Portlogan D24W Whauphill D37W Maisonette – upper floor Kirkcolm D12W Portpatrick D25W Whithorn D38W

Kirkcowan D13W Portwilliam D26W Wigtown D39W

14 15 16 West (Stewartry) Exceptions

Crossmichael D09S Kirkgunzeon D18S Springholm D27S 7.

Dalbeattie D10S Laurieston D19S Twynholm D28S 8. 9. 10.

West (Wigtown)

Tick Tick Tick Please tell us what type of property you would like. (√) Area/Town (√) Area/Town (√) Area/Town You may tick as many boxes as you wish. Cairnryan D02W Kirkinner D14W Sandhead D27W

Kirkcowan D13W Portwilliam D26W Wigtown D39W

15 16 15 Section 9 – Your housing history Joint Applicant

Please provide full addresses, dates and landlords’ contact details for the previous 5 years. Date from/ Tenure Reason for Address Contact details for landlord We use this information to request tenancy references. date to type leaving Name: Main Applicant Date from/ Tenure Reason for Address: Address Contact details for landlord date to type leaving Name:

Address: Tel no:

Name:

Tel no: Address:

Name:

Address: Tel no:

Name:

Tel no: Address:

Name:

Address: Tel no:

Name:

Tel no: Address:

Name:

Address: Tel no:

Have you been evicted from a tenancy within the last 3 years? Yes No Tel no: If yes, please give reason

Have you been evicted from a tenancy within the last 3 years? Yes No If yes, please give reason

16 17 18 Section 9 – Your housing history Joint Applicant

Address: Tel no:

Name:

Tel no: Address:

Name:

Address: Tel no:

Name:

Tel no: Address:

Name:

Address: Tel no:

Name:

Tel no: Address:

Name:

Address: Tel no:

Have you been evicted from a tenancy within the last 3 years? Yes No Tel no: If yes, please give reason

Have you been evicted from a tenancy within the last 3 years? Yes No If yes, please give reason

17 18 17 Section 10 – Personal connection Section 11 -– Contacts

The landlords covered by this application form are controlled by the following governing If you did not fill in this form yourself, please give details of the person who did structures: Name Dumfries & Galloway Housing Partnership – Board of Management Address Irvine Housing Association – Board of Management Home inGroup Scotland – Board – Board of Management of Management Cunninghame Housing Association – Board of Management Contact telephone number Yes No If yes, please complete: Do you want this person or any other person to make enquiries Yes No (√) (√) Name of related Main Applicant Landlord * Relationship regarding your application on your behalf in the future? (if yes and person their and details are different to the above, please give Are you a member of any of the Boards of details below) Management outlined above? Have you been a member of any of these Name Boards of Management in the previous 12 Address months? Are you a *close connection of a current or former member of any Boards of Management Contact telephone number described above? Do you want this person to be the main contact regarding your Yes No Are you a current employee of any of the housing application in the future? (that would mean that all above landlords? correspondence regarding your application would go to them) Have you been employed by any of the above landlords in the previous 12 months? Are you a *close connection of an employee of any of the above landlords? Section 12 – Additional information Are you a *close connection of anyone employed by one of the above landlords in the previous 12 months? Are there any circumstances you would want us to take account of including any additional support requirements you may have? (Please use the space below) Yes No If yes, please complete: (√) (√) Name of related Joint Applicant Landlord * Relationship person Are you a member of any of the Boards of Management outlined above? Have you been a member of any of these Boards of Management in the previous 12 months? Are you a *close connection of a current or former member of any Boards of Management described above? Are you a current employee of any of the above landlords? Have you been employed by any of the above landlords in the previous 12 months? Are you a *close connection of an employee of any of the above landlords? Are you a *close connection of anyone employed by one of the above landlords in the previous 12 months?

*Close connection – this includes family members as well as persons who might reasonably be regarded as similar to family members, even where there is no relation by N.B. Please ensure that you have signed the Declaration on page 3 before returning this form. birth or in law. Also includes people closely associated with you, for example the partners of immediate family members, their parents/child or siblings, someone who is dependent on you or vice versa, close friends, other relatives (aunts/uncles/nephews - and their partners), neighbours, business contacts or someone you are acquainted with socially. 20 18 19 Section 10 – Personal connection Section 11 -– Contacts

The landlords covered by this application form are controlled by the following governing If you did not fill in this form yourself, please give details of the person who did structures: Name Dumfries & Galloway Housing Partnership – Board of Management Address Irvine Housing Association – Board of Management Home in Scotland – Board of Management Cunninghame Housing Association – Board of Management Contact telephone number Yes No If yes, please complete: Do you want this person or any other person to make enquiries Yes No (√) (√) Name of related Main Applicant Landlord * Relationship regarding your application on your behalf in the future? (if yes and person their and details are different to the above, please give Are you a member of any of the Boards of details below) Management outlined above? Have you been a member of any of these Name Boards of Management in the previous 12 Address months? Are you a *close connection of a current or former member of any Boards of Management Contact telephone number described above? Do you want this person to be the main contact regarding your Yes No Are you a current employee of any of the housing application in the future? (that would mean that all above landlords? correspondence regarding your application would go to them) Have you been employed by any of the above landlords in the previous 12 months? Are you a *close connection of an employee of any of the above landlords? Section 12 – Additional information Are you a *close connection of anyone employed by one of the above landlords in the previous 12 months? Are there any circumstances you would want us to take account of including any additional support requirements you may have? (Please use the space below) Yes No If yes, please complete: (√) (√) Name of related Joint Applicant Landlord * Relationship person Are you a member of any of the Boards of Management outlined above? Have you been a member of any of these Boards of Management in the previous 12 months? Are you a *close connection of a current or former member of any Boards of Management described above? Are you a current employee of any of the above landlords? Have you been employed by any of the above landlords in the previous 12 months? Are you a *close connection of an employee of any of the above landlords? Are you a *close connection of anyone employed by one of the above landlords in the previous 12 months?

0300 123 1230 www.homes4dg.org.uk [email protected]

Homes4D&G Partner Landlords

Dumfries & Galloway Housing Partnership Home Scotland Home Scotland Dumfries &Grierson Galloway House Housing Partnership PavilionPavilion 6, Parkway6, Parkway Court Court TheGrierson Crichton House 321321 Springhill Springhill Parkway Parkway BankendThe Crichton Road BailliestonBaillieston DumfriesBankend Road GlasgowGlasgow DG1Dumfries 4ZS G69G69 6GA 6GA DG1 4ZS

Cunninghame HA Irvine Housing Association IrvineQuayside Housing Offices Association 8244-46 – 84 Bank Glasgow Street Street Marina44-46 Bank Quay Street IrvineArdrossan Dock RoadIrvine NorthAyrshire Ayrshire ArdrossanAyrshire LA12KA22 0LP 8EH KA22LA12 8DA 0LP