<p>NOMAD SmartRenting Scheme- 21-35 year olds Application Form Name of Applicant: ………………………………………………………………………. Date of Application :………………………………………………. Age: Single Yes/ No Couple Yes/ No Do you have any children living with you? Yes/ No Are you presently homeless? Yes/No Have you ever experienced homelessness before? Yes/No Are you in priority need? Yes/ No Do you have a letter confirming this decision? Yes/ No</p><p>Referring Agency:</p><p>Flow/ Returner?</p><p>Referral Yes/ No Criteria met Yes/ No Assessment Yes/ No Logged booked</p><p>1 Section A – Person </p><p>Print Name: …………………………………………………………………………………….. Date of birth: Date: ……… Month ……… Year………….. Age: ……………..</p><p>NI number: ……………………………………………………………………………………..</p><p>Contact Address: ………………………………………………………………………………..</p><p>Postcode: ……………………………………………………………………….</p><p>Is this a c/o address (friend/family/agency?) Yes No </p><p>If YES please give details………………………………………………………. Phone………………………………………………… Mobile……………………………………… Is it OK to leave message at this address/telephone number? Yes No </p><p>Next of kin: …………………………………………………………………………………………………</p><p>Relationship to you: ……………………………………………………………………………………….. Contact Address:…………………………………………………………………………………………… Telephone number: ………………………………………………………………………………………</p><p>Did anyone refer you here? (Tick one)</p><p>Alcohol agency Housing dept SS (young people) CPN / mental health team SS Probation Other Voluntary sector Other: …………………………. Drugs Agency Self </p><p>2 Section B – Equal Opportunities Monitoring </p><p>How do you describe your ethnic origin? (Tick one) </p><p>White English Black – Caribbean Mixed – White & Black African White Welsh Other black background Mixed – White & Black Caribbean White Scottish Asian – Pakistani Mixed – White & Black British White Irish Asian – Bangladeshi Mixed – White & Asian Other white background Asian – British Chinese Black – British Asian – Indian Did not answer Black – African Other Asian background Other …………………………. </p><p>How would you describe your current status? (Tick one)</p><p>Single male Single parent male Couple w/out children (male) Single female Single parent female Couple w/out children (female) Family (female) Family (male) Same sex couple w/out children (female) Same sex couple w/out children (male) If there are children, please state how many?...... </p><p>Do you have access to children?...... </p><p>Section C – Housing Situation </p><p>What is your current housing situation? (Tick one)</p><p>B & B or other temporary accommodation Private rented Children’s home Rough sleeper Foster care RSL Hostel Squatting Local Authority accommodation Staying with friends Mobile home Staying with parents NFA / sofa surfer Staying with relatives Night shelter Supported accommodation (long term) Owner occupier Tied accommodation Prison Other (please specify)……………………………</p><p>What is the principal reason for you being homeless or vulnerable to homelessness? (Tick one)</p><p>Asked to leave Landlord sold property Armed forces Leaving prison Asylum seeker Mortgage repossession Bereavement End of shorthold (NTQ)</p><p>3 Disrepair Property too expensive Eviction tenancy – arrears Relationship breakdown (separation) Eviction tenancy – anti-social behaviour Relationship breakdown (parents) Eviction hostel / temporary accommodation Relapsed from dry house Hospital discharge Rough sleeping Harassment from landlord Unsuitable accommodation Harassment from neighbours Violence at home (domestic) Left by choice Violence at home (racial / other) Leaving care Other (please specify)……………………………… </p><p>Have you ever slept rough? Yes No</p><p>When was the last time you slept rough? Day ………. Month ……… Year ……….</p><p>Overall how long have you slept rough for? (Tick one) </p><p>Less than 1 week 6 – 12 months Over 10 years 1 week – 1 month 1 – 2 years Never 1 – 3 months 2 – 5 years Did not want to answer 3 – 6 months 5 – 10 years</p><p>Where did you stay last night? (Tick one) </p><p>Family home NFA Prison Hostels / B&B temp Night shelter Rough sleeping Friends / relatives / partner Own home Squatting Other institution (please specify)…………………………</p><p>Do you have a Homeless case? Yes No</p><p>Do you have priority with the Homeless section? Yes No</p><p>Details of outcomes with Homeless Section: ……………………………………………………………………….</p><p>………………………………………………………………………………………………………………………………...... </p><p>4 Section D – Additional Support</p><p>Do you consider yourself to have a disability? Yes No </p><p>Are you registered disabled? Yes No</p><p>Are you currently taking any medication? Yes No</p><p>Give details of current / past health problems. (E.g. epilepsy, diabetics, high blood pressure)</p><p>...... </p><p>...... </p><p>...... </p><p>Have you had any mental health problems? Yes No</p><p>If yes, give brief details of past mental health history...... </p><p>...... </p><p>...... </p><p>Are you involved with any mental health services? Yes No </p><p>If yes, detail which ones (include dates and key contacts): ………………………………………………………</p><p>……………………………………………………………………………………………………………………………..…</p><p>Have you got any of the following needs/problems? </p><p>Welfare benefits Training / employment Debt / money advice Loneliness Mental health Cooking Drugs Personal care advice Alcohol Housing advice / accommodation Life skills Other (please specify)……………………………… Any further comments regarding support needs? (Give details of any other organisations involved in </p><p>Offering support)………………………………………………………………………………………………………</p><p>……………………………………………………………………………………………………………………………</p><p>What other organisations are involved?</p><p>SS Young people Other vol. sector Probation CPN Drugs agency Other NHS Alcohol GP CPN / Mental health team Private Rented Standards</p><p>Section E – Income & Debts</p><p>5 How would you describe your current employment status? (Tick one)</p><p>Sick / disabled Unemployed Student full time Working full time Student part time Working part time Training full time Working full time – self- employed Training part time Working part time – self-employed</p><p>If you are currently employed, what is the length of your contract?...... </p><p>What is your income (net of NI and tax)? £……………………per week</p><p>Are there any other deductions (e.g. attachment of earnings)? ...... </p><p>Are you currently in receipt of any benefits? Yes No</p><p>If YES please tick receiving benefit and list weekly amount of award: </p><p>JSA(C) £………… JSA (IB) £………….. ESA £…………… IS £……………. </p><p>Are you claiming benefits as a couple? Yes No</p><p>Other DSS benefits eg. Child Benefit DLA ………………………………… Other sources of income eg. Maintenance………………………………… Debts Rent arrears Amount £…..… Payment arrangements ……………………………………… Water arrears Amount £…..… Payment arrangements...... CTax arrears Amount £…..… Payment arrangements...... Gas arrears Amount £…..… Payment arrangements...... Electric arrears Amount £…..… Payment arrangements ...... Credit/store cards Amount £…..… Payment arrangements...... Overdraft Amount £…..… Payment arrangements...... Social fund Amount £…..… Payment arrangements...... Court fines Amount £...…… Payment arrangements...... </p><p>Are your financial circumstances about to change? Yes No If so, how? …………………………………………………………………………………………………………………… ...... </p><p>...... </p><p>6 Section F – Legal </p><p>Have you ever served time in Prison? Yes No If yes, give details: …………………………………………………………………………………………………………...... </p><p>Do you have a probation officer/named worker? ...... Yes No</p><p>Name: ……………...…………………………………………………………………………………………………………. Contact Tel: …...……………………………………………………………………………………………………………..</p><p>Give Details: ………………………………………………………………………………………………………………..</p><p>Section G – Housing Preferences</p><p>Which areas would you consider? (Give details) </p><p>Which areas would you NOT consider?...... </p><p>Do you have any children and if so how many? …………………</p><p>Is there regular access to any children? Yes No </p><p>If so, does this affect your accommodation needs? (Give details)</p><p>...... </p><p>Are there any other factors which may affect the suitability or otherwise of a property (i.e. pets, mobility)?</p><p>...... </p><p>...... </p><p>7 Section H – Other people to be housed with Applicant</p><p>Partner </p><p>Name...... </p><p>Gender…………… Age……………</p><p>Person one Name...... </p><p>Gender…………… Age……………</p><p>Relationship to main applicant...... </p><p>Section I – Evidence for Housing Benefit</p><p>(Please state what forms of evidence has been viewed) </p><p>Identity (e.g. medical card, birth certificate, driving licence): …………………………………………….…………...</p><p>National Insurance Number (e.g. DWP letter, NINO card, payslip): ……………………………………………….</p><p>Do you have a bank account? Yes No </p><p>Evidence of Bank Account (e.g. bank statement): ……………………………………………………………………</p><p>Is this a joint account? Yes No </p><p>If so, state name of joint account holder and relationship to applicant: …………………...... </p><p>………………………………………………………………………………………………………………………………..</p><p>8 Section J – Sustaining a Tenancy</p><p>Does this client require low level Resettlement Support? Yes No </p><p>Does this client require medium / high level Resettlement Support? Yes No </p><p>Please give reasons for your answer:.…………………………………….. …………………...... </p><p>………………………………………………………………………………………………………………………………..</p><p>………………………………………………………………………………………………………………………………..</p><p>………………………………………………………………………………………………………………………………..</p><p>Will this client require direct payments to landlord? Yes No </p><p>If yes, please provide reasons why: …………………………………….. …………………...... </p><p>………………………………………………………………………………………………………………………………..</p><p>………………………………………………………………………………………………………………………………..</p><p>……………………………………………………………………………………………………………………………</p><p>Referrers Signature …..</p><p>Applicants Signature </p><p>PLEASE RETURN THIS FORM TO:</p><p>Nomad, 12-14 Burngreave Road, Sheffield, S3 9DD, telephone 01142412080, fax 01142787468</p><p>9</p>