Harrogate BOROUGH COUNCIL OFFICE USE ONLY HOUSING Date received: Acknowledged: Date logged: APPLICATION Inputting Officer: Application No: Please use block capitals when completing this form and provide as much information as possible as this will help us to assess your points accurately. You will need to complete every question that applies to you otherwise your application may be rejected. Please note that before you start your application you will need your National Insurance number, your address history for the last five years and, if applicable, your landlord's contact details for your current and previous addresses. Further details on our housing allocation scheme can be found on our website at www.harrogate.gov.uk. If you need any advice or help to complete this form please contact Customer Services on 01423 500600. Personal details Q1 Main applicant Q2 Joint applicant Mr/Mrs/Miss/Ms (please delete) Mr/Mrs/Miss/Ms (please delete) Last name Last name First name(s) First name(s) Date of birth Date of birth / / / / Your current address or a contact address Please tell us your relationship to the main applicant, for example, spouse, partner. Your current address or a contact address Postcode Your contact telephone number Postcode Email address Your contact telephone number National Insurance number Email address Gender: Male/Female/Other (please delete) National Insurance number Next of kin Gender: Male/Female/Other (please delete) Name Telephone Next of kin Name Telephone We want to shape our housing service to meet the needs of our customers and to make sure that everyone is treated fairly and able to access the service as easily as possible. Questions 3 to 9 are not compulsory but the information Q5 Please enter your religion: you provide will help us to do this. Main Joint Q3 Details of your relationship status applicant applicant (please tick): Buddhist Main Joint applicant applicant Christian Hindu Single Jewish Married/Civil Partnership Sikh Partner Muslim Separated Other Divorced No religion Co-habitee Prefer not to say Widow Widower Q6 Which of the following best Do not wish to declare describes how you think of Q4 Your ethnicity (please tick): yourself? Main Joint Main Joint applicant applicant applicant applicant Asian or Asian British Bangladeshi Bisexual Asian or Asian British Indian Gay man Asian or Asian British Pakistani Heterosexual/straight Asian or Asian British other Gay woman/lesbian Asian Other Bangladeshi Prefer not to say Black or Black British African Black or Black British Caribbean Q7 Is English your first language? Black or Black British other Main applicant Yes No Black African Black Caribbean If no, please tell us what your first language is. Black other Chinese Joint applicant Yes No Gypsy Roman Traveller Indian If no, please tell us what your first language is. Mixed other Mixed White Asian Mixed White and Black Caribbean Mixed White and Black African Q8 Do you need this information Pakistani translated into another language? White Yes No White British If yes, what language do you want this White other translating into? Other Do not wish to declare Household personal details (other adults) Q9 Does anyone in the household have a Q10 Please give details of everyone disability under the Equality Act? who needs housing with you. Yes No Mr/Mrs/Miss/Ms (please delete) The definition of a disability according to the Equality Act 2010 is: “A physical or mental impairment which has Last name a substantial and long-term adverse effect on his or her ability to carry out normal day to day activities”. Long-term means more than 12 months. The definition covers long- First name(s) term illnesses such as cancer and HIV or mental health; it includes any adult or child living permanently in the household. Date of birth If you answered 'yes' to the previous question please National Insurance number answer the further questions about disability below. If you would prefer not to answer these questions, please leave them blank. However, if you are happy to answer them please put a tick against each one that applies. Gender: Male/Female/Other (please delete) Physical disability Relationship to you for example mother, son. Visual impairment Speech impairment Mr/Mrs/Miss/Ms (please delete) Hearing impairment Mental health problems Last name Long term illness First name(s) Difficulties reading or writing Learning disability Date of birth Disability not listed above Please give details here National Insurance number Gender: Male/Female/Other (please delete) Relationship to you for example mother, son. If you need to list more adults who need housing with you, please use the space provided in the 'Additional Information' section Prefer not to say on the back page. Household personal details Main applicant (children) addresses Q11 Please give details of children who Q12 Starting with your current address, need housing with you. please tell us where you have lived over the last five years and who owned the Last name property, for example private landlord, council, housing association, parents. If you First name(s) are currently of no fixed abode, you must provide a correspondence address. Date of birth Property One Address Gender: Male/Female/Other (please delete) Relationship to you for example son, daughter. Date from / / Date to / / What is the landlord’s name and address? Do you receive child benefit for them? Yes No Last name Landlord's contact number/email First name(s) If not renting, what are your circumstances, for example lodging, owner-occupation. Date of birth Gender: Male/Female/Other (please delete) Relationship to you for example son, daughter. Property Two Address Do you receive child benefit for them? Yes No Date from / / Date to / / Last name What was the landlord’s name and address? First name(s) Date of birth Landlord's contact number/email Gender: Male/Female/Other (please delete) If not rented, what were your circumstances, for Relationship to you for example son, daughter. example lodging, owner-occupation. Do you receive child benefit for them? Yes No Why did you leave? If you need to list more children who need housing with you, please use the space provided in the 'Additional Information' section on the back page. Q13 If you are liable for rent in your current property, are you in rent arrears? Yes No Property Three If Yes, please provide details. Address Date from / / Date to / / What was the landlord’s name and address? Landlord's contact number/email Q14 If you are currently of no fixed abode, or lodging with family/friends on If not rented, what were your circumstances, for example lodging, owner-occupation. a temporary basis, please provide details of any rent arrears you accrued at your last settled address. Why did you leave? Property Four Address Date from / / Date to / / Q15 Have you or anyone included in this application ever had a tenancy in a What was the landlord’s name and address? Harrogate Borough Council property that is not your current property or a property already mentioned? Landlord's contact number/email Yes No If yes, please provide details If not rented, what were your circumstances, for example lodging, owner-occupation. Why did you leave? If you need to list more properties, please use the space provided in the 'Additional Information' section on the back page. Property Three Joint applicant Address addresses Date from / / Date to / / Please provide this information if the address What was the landlord’s name and address? history differs from that of the main applicant. Q16 Starting with your current address, please tell us where you have lived over Landlord's contact number/email the last five years and who owned the property, for example private landlord, council, housing association, parents. If you If not rented, what were your circumstances, for are currently of no fixed abode, you must example lodging, owner-occupation. provide a correspondence address. Why did you leave? Property One Address Property Four Date from / / Date to / / Address What is the landlord’s name and address? Date from / / Date to / / What was the landlord’s name and address? Landlord's contact number/email If not renting, what are your circumstances, for example Landlord's contact number/email lodging, owner-occupation. If not rented, what were your circumstances, for example lodging, owner-occupation. Why did you leave? Property Two Address If you need to list more properties, please use the space provided in the Additional Information Date from / / Date to / / section on the back page. What was the landlord’s name and address? Q17 If you are liable for rent in your current property, are you in rent arrears? Landlord's contact number/email Yes No If Yes, please provide details If not rented, what were your circumstances, for example lodging, owner-occupation. Q18 If you are currently of no fixed Why did you leave? abode, or lodging with family/friends on a temporary basis, please provide details of any rent arrears you accrued at your last settled address. Q21 What is your local connection to Your current the district? circumstances Our local connection criteria is explained on our website www.harrogate.gov.uk/localconnection in the housing allocation scheme summary information booklet. Q19 If you or any of the people moving In addition to your five year address history with you are not UK citizens, please detailed in questions 12 and 16, please provide provide details and confirm which any additional local connection details (for country they are a citizen of. example name, address, relevant dates of residency/employment). Previous resident - this applies if you have previously lived in the district for a continuous period of ten years. Family who live in the area (please give full details of Q20 In the past five years, if you or their names, addresses, relationship to you and how anyone moving with you have come long they have lived in the Harrogate district).