Housing Application Form

"*" indicates required fields

Step 1 of 11 - Welcome

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This field is for validation purposes and should be left unchanged.

Please state which village/parish you are applying for*

Are you registered with:

Cornwall Homechoice

Council of the Isles of Scilly

Have you applied to us before?*

Yes

When did you apply?*

DD slash MM slash YYYY

Gender*

Male

Female

Non disclosed

Non binary

Other

Title

Name*

First Middle Last

Previous last name (if applicable)

Date of birth*

DD slash MM slash YYYY

Address*

Address Line 1 Address Line 2 City Postcode

Contact phone number*

Additional contact phone number

Email address*

National Insurance Number*

Passport number & expiry date*

Is there a joint applicant?*

Yes

Gender*

Male

Female

Non disclosed

Non binary

Other

Title

Name*

First Middle Last

Previous last name (if applicable)

Date of birth*

DD slash MM slash YYYY

Address*

Address Line 1 Address Line 2 City Postcode

Contact phone number*

Additional contact phone number

Email address*

National Insurance Number*

Passport number & expiry date*

Please give details of all the people you want to be re-housed with you.

Do not include yourself or the joint applicant.

How many people, excluding yourself and the joint applicant, will be re-housed with you?*

Person 1

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 2

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 3

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 4

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 5

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 6

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 7

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 8

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 9

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 10

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 11

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 12

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 13

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 14

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 15

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 16

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 17

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 18

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 19

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 20

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 21

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 22

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 23

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 24

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Person 25

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Is this person living with you now?*

Yes

Address*

Address Line 1 Address Line 2 City Postcode

Are any of the above people expecting a baby?*

Yes

Who is expecting?*

When is the baby due?*

DD slash MM slash YYYY

Please give details of anyone living with you who will not be moving with you.

How many people are living with you who will not be moving with you?*

Person 1

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 2

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 3

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 4

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 5

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 6

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 7

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 8

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 9

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 10

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 11

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 12

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 13

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 14

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 15

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 16

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 17

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 18

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 19

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 20

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 21

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 22

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 23

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 24

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

Person 25

Name*

First Last

Gender*

Male

Female

Non disclosed

Non binary

Other

Date of birth*

DD slash MM slash YYYY

Age*

Relationship to you*

How many bedrooms are there?*

What is the full rent of the property?*

Please enter a number greater than or equal to 0.

Rent period*

per week

per month

Do you receive help with rent from Housing Benefit?*

Yes

How much Housing Benefit?*

Please enter a number greater than or equal to 0.

Housing Benefit period*

per week

per month

Do you receive help with rent from Universal Credit?*

Yes

How much Universal Credit?*

Please enter a number greater than or equal to 0.

Universal Credit period*

per week

per month

Which of the following do you live in?*

House / bungalow

Flat / maisonette

Bedsit

Caravan / mobile home

Bed and breakfast

Hostel

Hospital

Lodgings or digs

Sleeping rough

In an institute

Other

Which floor is it on?*

Ground

First

Second or above

Do you have use of a lift?

Yes

Are you?*

A council tenant

A housing association tenant

In a property that comes with a job

A tenant of a private landlord

A home owner or buyer

Sharing with friends or relatives

Other

If you are a tenant now, please give the landlord's name and address

When did you move into your present address?*

DD slash MM slash YYYY

Address history

If you have lived at your present address for less than three years, please give details of your last two addresses:

Previous address 1

Address Line 1 Address Line 2 City Postcode

From Date

DD slash MM slash YYYY

To Date

DD slash MM slash YYYY

Reason for leaving

Previous address 2

Address Line 1 Address Line 2 City Postcode

From Date

DD slash MM slash YYYY

To Date

DD slash MM slash YYYY

Reason for leaving

Do you either lack or share any of the following amenities with anyone who will not be moving with you:

Bathroom*

Lacking

Sharing

Neither

Inside toilet*

Lacking

Sharing

Neither

Hot water supply*

Lacking

Sharing

Neither

Kitchen*

Lacking

Sharing

Neither

Living room*

Lacking

Sharing

Neither

Does your present housing suffer from any of the following:

Leaking roof or walls

Rainwater entering property

Damp

Rotting wood (floorboards, windows or doors)

Faulty or old wiring

Lack of heating

Other

Please specify*

Reasons why you need re-housing*

People apply to us for re-housing for many reasons. Please tick the boxes which best describe why you are applying:

Relationship breakdown

Need a larger property

Living apart from family

Need a smaller property

Building Society/Bank repossession

To leave home

Losing home with job

To take up work in this area

Have an eviction order

To live together/get married

Have received formal notice to quit

Pregnancy

Landlord is selling

To be nearer friends or relatives

Leaving hospital or other institution

Sexual harassment/abuse

Asked to leave by friends/relatives

Racial harassment

Leaving armed forces

Domestic violence

Emergency flood/fire

Physical abuse

Can't afford present housing

Other harassment

Health reasons

Other reasons

Please specify*

Please upload evidence to support your application

Max. file size: 8 MB.

Please give any further details that you feel are important in the space below:

If you must leave your present home, when must you leave by?

DD slash MM slash YYYY

If you are homeless, are you registered with the local authority housing options team?*

Yes

N/A

Are there any other agencies involved (e.g. social workers, doctors)?*

Yes

Please give details below if you are happy for us to contact them:

Do you or someone wishing to live with you suffer from a long standing illness or permanent disability which is affected by your present housing?*

Yes

Name of person with the health problem:*

First Last

Details of the health problem and how it is affected by your present housing*

Does anyone to be re-housed use a wheelchair in the property?*

Yes

Does anyone to be re-housed have difficulty climbing stairs?*

Yes

Is anyone to be re-housed disabled?*

Yes

Has your present home been adapted in any way for disabled use?*

Yes

In which way has it been adapted:*

We generally can only consider applications from people who have a connection with a village parish where we have properties.

Where do you want to be re-housed?*

Do you currently live in the above parish?*

Yes

How long have you lived in the above parish?*

Have you lived in the above parish in the past?*

Yes

Please give dates:*

Are you employed in the parish?*

Yes

Please give details:*

If you do not live or work in the parish, please give details of your connection:

Please give the total weekly amount of take home pay and/or pensions and benefits for yourself and any joint applicant. If none, please enter 0.

Normal take home pay (per week) £*

Please enter a number greater than or equal to 0.

Total amount from any pensions (per week) £*

Please enter a number greater than or equal to 0.

Total amount from any benefits (per week) £*

Do not include Housing or Child Benefit

Please enter a number greater than or equal to 0.

Total savings £*

What is the total amount of savings to the nearest £1,000 that you and any joint applicant have in either a bank account, building society, post office or investment? If less than £1,000 enter 0.

Please enter a number greater than or equal to 0.

If you own your own house, what do you think it is worth? £*

Please enter a number greater than or equal to 0.

How much mortgage is there left to pay? £*

Please enter a number greater than or equal to 0.

Joint Applicant

Normal take home pay (per week) £*

Please enter a number greater than or equal to 0.

Total amount from any pensions (per week) £*

Please enter a number greater than or equal to 0.

Total amount from any benefits (per week) £*

Do not include Housing or Child Benefit

Please enter a number greater than or equal to 0.

Total savings £*

What is the total amount of savings to the nearest £1,000 that you and any joint applicant have in either a bank account, building society, post office or investment? If less than £1,000 enter 0.

Please enter a number greater than or equal to 0.

If you own your own house, what do you think it is worth? £*

Please enter a number greater than or equal to 0.

How much mortgage is there left to pay? £*

Please enter a number greater than or equal to 0.

CRHA will aim to help reduce the disadvantages that people experience by making our services more responsive to all communities and individual needs.

CRHA values the diversity of all communities and we want our services, facilities and resources to be accessible.

CRHA will from time to time collect information for equalities monitoring. Details on how this information is used are available in CRHA’s Privacy Notice.

Applicant signature (and joint applicant if applicable)*

I declare that the information given on this form is true and accurate to the best of my belief. I understand that if a false statement is discovered after an offer of tenancy has been made the Association will commence legal proceedings for possession of the property.

I agree to provide any further relevant information as requested if it is reasonable and necessary to determine the application.

I authorise the Association to approach third party organisations such as employers, if necessary to do so. I understand that this does not affect my rights under the Data Protection Act 2018 or any subse- quent legislation.

I will advise the Association of any changes to my circumstances which could affect this application.

I do not object to the information on this form being used for statistical purposes provided that confidentiality is maintained.

I agree

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