Number
Name
APPLICATION
FOR HOUSING
Please answer ALL the questions on the form, they are all relevant to determining your application. For every
applicant, include at least two forms of proof of identity and proof of current address.
Failure to answer all the questions and providing the necessary proofs could lead to a delay in us dealing
with your application.
Forms of identification include
Full birth certificate
Medical card
Marriage certificate
Driving licence
Passport
Proof of Benefit entitlement Tenancy
Agreement
Proof of current address include
Recent Bank Statement
Council Tax Bill
TV Licence
Recent Utility Bill (eg. Gas / Electricity /Telephone
but not Mobile phone)
For every child included on the application form we will need proof of child tax credit.
We must see the original documents, photocopies will not be acceptable.
When completed please return this form to:
Housing Services
Sherwood Lodge
Bolsover
Derbyshire
S44 6NF
Tel:
01246 242424
Email:
enquiries@[Link]
Website: [Link]
or any of our Contact Centres, please see address on Page 19.
Providing Access for All - Please see statement on Page 26
Page 1
SECTION A
YOU AND YOUR HOUSEHOLD
APPLICANT
JOINT APPLICANT
Present address:
Present address:
Post Code:
Post Code:
Correspondence address (if different from above)
Correspondence address (if different from above)
Post Code:
Post Code:
Length of time at current address :
Length of time at current address :
Mr
Mr
Mrs
Miss
Ms
Mrs
Miss
Ms
Other - please state
Other - please state
First Name(s):
First Name(s):
Surname:
Surname:
National
Insurance No. :
National
Insurance No. :
Date of Birth:
Date of Birth:
Single
Married
Separated
Divorced
Widowed
Living
together
Single
Married
Separated
Divorced
Widowed
Living
together
Relationship to applicant one eg. spouse, child,
partner etc. :
Home Tel. No. :
Home Tel. No. :
Work Tel. No. :
Work Tel. No. :
Mobile Tel. No. :
Mobile Tel. No. :
EMail Address :
EMail Address :
Village / Town
of Origin:
Village / Town
of Origin:
Page 2
Have you, your partner / joint applicant ever been known by another name?
Yes
No
If yes, please give details:
Please list everyone wishing to be rehoused with you (including children)
Full name
Sex
(M/F)
Date of
birth
Age
Relationship to
applicant
Currently living with
applicant (tick)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
If anyone included in the application lives at a different address, please enter their details below:
Full name
Address
Reason for living apart
Please give details of anyone who shares your accommodation at present but is not to be rehoused with
you:
Surname
First name
Relationship
Date of birth
If you have access to children, please give these details and provide proof of access for example, joint
residency order, letter from solicitor, letter from ex-partner:
Childs name
Age
Date of birth
Page 3
Number of days
access each week
Is anyone wishing to be rehoused expecting a baby?
Name of Person
Yes
No
Date when baby is due
PLEASE ATTACH A COPY OF YOUR CERTIFICATE CONFIRMING PREGNANCY. ALSO PROVIDE A COPY OF
BIRTH CERTIFICATE WHEN CHILD BORN
EMPLOYMENT AND INCOME
APPLICANT
JOINT APPLICANT
Occupation :
Occupation :
Employer :
Employer :
Address:
Address:
Post Code:
Post Code:
Working full time
Working full time
Working part time
Working part time
Government training / New Deal
Government training / New Deal
Job Seeker
Job Seeker
Retired
Retired
Full time student
Full time student
Unable to work
Unable to work
Carer
Carer
Number of
hours worked :
Number of
hours worked:
Do you currently claim any benefits?
Yes
No
If yes, what benefits do you claim?
Please list all below:
Continued overleaf ......
Page 4
Do you have any close relatives living in the Bolsover District Council area?
If yes please specify
Name
Address
Yes
Relationship
Page 5
No
SECTION B
WHERE YOU LIVE NOW
Please list all of your previous addresses during the last 10 years. Please start with your present address:
APPLICANT
Address
Please indicate if
Council or Housing
Association, Private
Tenant, Owner
Occupier or Other
Dates From / To
Reason for Leaving
JOINT APPLICANT
Do you have any of the following in your present accommodation? (please tick):
None
Sole Use
A bedroom
A bathroom
Inside toilet
Outside toilet
Hot water
Mains cold water
Kitchen (including cooking facilities)
Living room
Steps at front
Steps at rear
Means of heating
Page 6
Shared
Is shared with whom
INFORMATION ABOUT YOUR HOME
APPLICANT
JOINT APPLICANT
Are you : (please tick only one)
Are you : (please tick only one)
A council tenant
In hospital
A council tenant
In hospital
A housing
association tenant
In housing for
older people
A housing
association tenant
In housing for
older people
An owner occupier
An owner occupier
(low cost home
ownership)
A private tenant
In tied housing
In supported
housing
In a probation
hostel
In a residential
care home
In prison
An owner occupier
In any other
temporary
accommodation
An owner occupier
(low cost home
ownership)
In a foyer
A private tenant
In short life
housing
In tied housing
In a mobile home/
caravan
In supported
housing
In a refuge
In a probation
hostel
In a direct access
hostel
In prison
In any other
temporary
accommodation
In a foyer
In short life
housing
In a mobile home/
caravan
In a refuge
In a direct access
hostel
In bed & breakfast
In a residential
care home
In bed & breakfast
Living with family
Rough sleeping
Living with family
Rough sleeping
Living with friends
Childrens home/
foster care
Living with friends
Childrens home/
foster care
Home office
asylum support
Home office
asylum support
Other
Other
If applicable, please give details of expected discharge date or release date and any arrangements made
thereafter
If private rented tenant or housing association tenant please give name and address of landlord and a
copy of your tenancy agreement
Page 7
What type of property do you live in? (tick one box) :
House
Bungalow
Sheltered housing
Flat
Ground Floor
First Floor
Hostel
Boat
Bedsit
Ground Floor
First Floor
Caravan
Mobile home
Maisonette
Ground Floor
First Floor
B&B
Sleeping rough
Other (please give details):
How many bedrooms does your current property have?
Does your property suffer from any disrepair which in your view affects your quality of life?
Yes
No
If yes please give details:
Why do you want to move? (you can tick more than one box)
You are overcrowded
Your property is too large for your family
Property unsuitable for medical reasons
Property is in poor condition
Affordability - mortgage / rent too high
To move nearer to family/friends/school
To move nearer work
To move to accommodation with support
To move to independent accommodation
Loss of tied accommodation
Assured shorthold tenancy has ended
Eviction or repossession
Domestic violence
Relationship breakdown with partner (non violent)
Asked to leave by family or friends
Harassment - racial/disability/gender/transgender/sexual orientation
Problems with neighbours
Left home country as refugee
Discharged from prison / long stay hospital
Decanted by Bolsover District Council to another
property
Other (please give details in box overleaf )
Page 8
Other Properties
Do you or your partner own or have a financial interest in any property that you are not living in?
Yes
No
If yes please give details:
Do you have any pets?
Yes
No
If yes please tell us what type and how many:
Page 9
SECTION C
HEALTH & SOCIAL FACTORS
Medical Factors
Social problems such as difficulties with neighbours or the dislike of the locality cannot be considered to be
medical problems. Please give brief details of any relevant health problems that affect you or any member
of your household. A further questionnaire will be issued to ascertain your medical priority:
Do you consider yourself or any member of your household to be disabled?
Yes
No
(For a definition of Disabled please see page 15)
Please describe how these medical problems are affected by your present home, eg unable to get
upstairs, difficulty using bathroom etc.
Has your present home been provided with adaptations, eg ramp, shower etc?
If yes please give details:
Page 10
Yes
No
Do you need to move to give / receive support for health reasons?
Yes
No
If yes please give details, including name and address of people concerned:
Do you have a GP, social worker, health or other advocate who can add support to your housing application
if requested:
Yes
No
If yes please give details :
Do you have a ....?
Name
Contact Address
Social Worker
Probation Officer
Health Visitor
Community Psychiatric Nurse
Connexion Personal Advisor
Is anyone helping you to be
rehoused
Page 11
Tel. Number
SOCIAL NEEDS FACTORS
Points may be awarded to applicants who may come to harm or whose welfare is at risk in their current
accommodation. Please tell us if you or anyone included in your application would qualify for these points
and why. We will need you to substantiate all claims before points are awarded.
Page 12
SECTION D
GENERAL INFORMATION
Failure to complete both pages 13 and 14 completely could result in your application for rehousing
not being considered.
Have you previously been evicted from a property owned by a local authority, housing association or
private landlord?
Yes
No
If yes please give details of address and reason:
Has a landlord ever started action against you or your household for anti social behaviour?
Yes
No
If yes please give details:
IMMIGRATION STATUS
Have you resided in the United Kingdom for the past 5 years?
Yes
No
If no please give details:
CONVICTIONS
Have you or any other person normally residing with you or who will be residing with you, ever been
convicted or have any prosecutions pending for any criminal offence?
Yes
No
If yes please give details:
Page 13
NATIONALITY
APPLICANT
JOINT APPLICANT
How would you describe your sexuality?
How would you describe your sexuality?
Heterosexual
Gay
Lesbian
Bisexual
Prefer not to say
Heterosexual
Gay
Lesbian
Bisexual
Prefer not to say
Have you lived in another country in the last five
years?
Have you lived in another country in the last five
years?
Yes
Yes
No
No
Austria
Latvia
Austria
Latvia
Belgium
Lithuania
Belgium
Lithuania
Cyprus
Luxembourg
Cyprus
Luxembourg
Czech Republic
Malta
Czech Republic
Malta
Denmark
Netherlands
Denmark
Netherlands
Estonia
Poland
Estonia
Poland
Finland
Portugal
Finland
Portugal
France
Slovakia
France
Slovakia
Germany
Slovenia
Germany
Slovenia
Greece
Spain
Greece
Spain
Hungary
Sweden
Hungary
Sweden
Ireland
Other - Where?
Ireland
Other - Where?
Italy
Italy
When did you come to live in this country?
D D
M M
When did you come to live in this country?
D D
/ YYYY
What is your nationality?
M M
/ YYYY
What is your nationality?
Page 14
EQUAL OPPORTUNITIES MONITORING FORM
This section is not relevant in determining your application, however completion of the relevant
details will help us to ensure we are providing a fair service.
APPLICANT
JOINT APPLICANT
Please tick the appropriate box to indicate your
cultural background :
Please tick the appropriate box to indicate your
cultural background :
A. White
A. White
C. Asian or Asian British
C. Asian or Asian British
British
Indian
British
Indian
Irish
Pakistani
Irish
Pakistani
Polish
Bangladeshi
Polish
Bangladeshi
Italian
Other
Italian
Other
Other
B. Mixed
Other
D. Black or Black British
B. Mixed
D. Black or Black British
British
Caribbean
British
Caribbean
White & Black
Caribbean
African
Other
White & Black
Caribbean
African
Other
White & Black
African
White & Black
African
E. Other Ethnic Group
E. Other Ethnic Group
White & Asian
Chinese
White & Asian
Chinese
Other
Gypsy
Other
Gypsy
Dual heritage
Dual heritage
Other
Other
Please tick the appropriate box to indicate your
religion or beliefs:
Please tick the appropriate box to indicate your
religion or beliefs:
None
Buddhist
Christian
None
Buddhist
Christian
Hindu
Jewish
Muslim
Hindu
Jewish
Muslim
Sikh
Other
Prefer not
to say
Sikh
Other
Prefer not
to say
Disability
The definition of Disability in the Disability Discrimination Act 1995 is A physical or mental impairment
which has substantial and long term adverse effect on a persons ability to carry out normal day to day
activities.
Do you consider yourself to be disabled?
Yes
No
Do you consider yourself to be disabled?
Yes
No
If yes, what are your impairments? Please tick all
that apply.
If yes, what are your impairments? Please tick all
that apply.
Mobility
Visual
Mobility
Visual
Speech
Hearing
Speech
Hearing
Wheelchair user
Learning Disability
Wheelchair user
Learning Disability
Mental Health
condition inc.
Depression
Long Standing
Health Condition
eg. Cancer, HIV
Mental Health
condition inc.
Depression
Long Standing
Health Condition
eg. Cancer, HIV
Other - Please State
Other - Please State
Page 15
OTHER HOUSING OPTIONS
Mutual Exchange
Council and Housing Association tenants may exchange properties providing they have written permission
from their landlords. The mutual exchange list is a way of finding someone to exchange with. If you apply,
the details about your property will be displayed on the mutual exchange list on the Internet and in
designated locations.
If you are interested please tick in the box provided
Shared Ownership
Shared ownership requires the applicant to buy a share of the price of a particular Housing Association
property (normally half ) and rent the remaining share from the Housing Association. The owned share can
be gradually increased until the whole property is bought.
If you are interested please tick in the box provided
Do you want to be considered for nomination to a Housing Association?
Yes
No
Do you want to be considered for nomination to a private landlord?
Yes
No
If you have answered yes to the above, we will need to share your information with other housing providers.
Please tell us if you dont want us and where it with a specific organisation. Please refer to mean data
protection statement on page 17.
Page 16
DECLARATION
Do you wish to give authorisation for someone to act on your behalf, for example, social worker, support
agency worker, family member. Please give name and contact details.
FOR THE ATTENTION OF ALL APPLICANTS
IMPORTANT NOTICE - HOUSING ACT 1996 - s.171 & s.214 - FALSE STATEMENTS
Where a person approaches the Housing Department seeking an allocation of housing or claiming to be
homeless or threatened with homelessness, the above Act makes it an offence, punishable with a fine,
for a person to make a false statement or to withhold information which is relevant to their claim. For
homeless applicants it is also an offence to fail to inform the housing authority of any material changes in
circumstances which may occur between the initial interview and such time as notification of the Councils
decision is received.
NATIONAL FRAUD INITIATIVE
NOTIFICATION TO DATA SUBJECTS (HOUSING RENTS)
The authority is under a duty to protect the public funds it administers, and to this end may use the
information you have provided on this form for the prevention and detection of fraud. It may also
share this information with other bodies responsible for auditing or administering public funds for
these purposes. For further information see [Link]/[Link] or
contact Mr John Brooks CPFA, Director of Resources 01246 242431.
FOR THE ATTENTION OF ALL APPLICANTS
DECLARATION
The information I provide is accurate. I understand that if I obtain accommodation by providing inaccurate
information, the Council may take legal action to recover the property.
Signature of applicant
Date
Signature of joint applicant
Date
I am an officer or member of Bolsover District Council or have been within the last 10 years.
I am a close relative / close friend of an officer or member of Bolsover District Council. Please give
name of officer/member
None of the above apply to me
If you are a relative / close friend of an officer or member, please state their name and the nature of your
relationship. (eg. son, daughter etc.)
Name
Relationship
All personal information provided to Bolsover District Council will be held and treated in
confidence in accordance with the Data Protection Act 1998. It will only be used for the purpose for
which it was given and may be shared with other council departments or third party organisations.
Page 17
WHAT ACCOMMODATION DO YOU NEED?
The type and size of accommodation that you may be offered will depend on the size of your family. Please
refer to the Bolsover District Council - Choice Based Letting Information Booklet for details of what you may
be eligible for.
Would you accept any type of property as long as it is suitable for your needs?
Yes
No
If NO, please tick the type(s) of property you would accept. Please note: If you are in a priority group you may
be offered any type of property suitable for your needs.
House
Bungalow
Sheltered Flat
Sheltered Bedsit
Ground Floor Flat
Housing with support
First Floor Flat
How many bedrooms do you want?
You cannot ask for a property larger than your family needs.
You can ask for a smaller property (for example, one bedroom less) with some exceptions.
See the Choice Based Letting Information Booklet for further details.
Page 18
CONTACT CENTRE AREAS WITH VILLAGES
Clowne Contact Centre Area
9 Church Street, Clowne, Derbyshire
Villages
Barlborough
Clowne
Creswell
Hodthorpe
Whitwell
Shirebrook Contact
Centre Area
2a Main Street,
Shirebrook, Notts
Villages
Langwith
Langwith Junction
Shirebrook
Whaley Common
Bolsover Contact
Centre Area
Sherwood Lodge,
Bolsover
Villages
Bolsover
Bramley Vale
Doe Lea
Glapwell
Hillstown
New Houghton
Palterton
Shuttlewood
Scarcliffe
Stanfree
OPENING TIMES
Office Opening Times
9.00am -5.00pm
Monday - Friday
9.00am - 12.30pm
Saturday
South Normanton
Contact Centre Area
124a Martket Street,
South Normanton, Derbyshire
Villages
Blackwell
Hilcote
Newton
Pinxton
South Normanton
Tibshelf
Westhouses
Telephone Lines
8.00am -5.00pm
9.00am - 12.30pm
Page 19
Monday - Friday
Saturday
Please tick the box next to the town/villages where you would accept an offer of housing.
Please note however that some villages have limited availability.
Barlborough
New houghton
Blackwell
Newton
Bolsover
Palterton
Bramley vale
Pinxton
Clowne
Scarcliffe
Creswell
Shirebrook
Shuttlewood
Doe lea
Stanfree
Glapwell
South normanton
Hilcote
Tibshelf
Hillstown
Westhouses
Hodthorpe
Whitwell
Langwith
Langwith junction
Please rank from the above town/villages your top three preferred areas:
First:
Second:
Third:
Page 20
ADDITIONAL INFORMATION
Please use this space to provide any other information which you feel may be relevant to your
application.
Page 21
OFFICE USE ONLY
Date
Information
Initials
Identification verified
Eligibility
Check for written off arrears
Rent - current FTA
Sundry Debts / recharges
Registration card issued
Page 22
AREA AND PROPERTY TYPE PREFERENCE
This section is not mandatory and is not relevant to determining your application for housing.
This information below is about where you would like to live and in what type of property. It is
not current property availability but will help our Strategy Team when considering what types of
accommodation we will need in our district in the future.
Please tick the area you would like to live in:
Clowne Contact Centre Area
Barlborough
Shirebrook Contact Centre Area
Upper Langwith
Langwith
Renishaw
Clowne
Spinkhill
Langwith Junction
Whaley
Creswell
Steetley
Pleasley
Whaley Thorns
Elmton
Whitwell
Shirebrook
Hodthorpe
Whitwell Common
Mastin Moor
Bolsover Contact Centre Area
Astwith
South Normanton Contact Centre Area
New Houghton
Blackwell
South Normaton
Carr Vale
Palterton
Broadmeadows
Stainsby
Bolsover
Scarcliffe
Hardstoft
Tibshelf
Bramley Vale
Shuttlewood
Newton
Westhouses
Doe Lea
Stanfree
Pinxton
Glapwell
Stoney Houghton
Hillstown
Please tick the type of accommodation you would prefer if available:
0 bed
House
n/a
Flat ground floor
n/a
Flat above ground floor
n/a
Bungalow
n/a
Sheltered accommodation
n/a
Bedsit
Social Rented
Shared Ownership
Page 23
1 bed
2 bed
3 bed
4 bed
4+bed
n/a
n/a
n/a
n/a
n/a
Page 24
WHAT TO DO NOW
Please check that you have . . .
Filled in and signed the application form for yourself, a joint applicant and other members of your
household, if applicable.
Included the required proof of identity and proof of address.
Checked the price of posting this form and any other supporting proof, if you are sending it through
the post. Failing to put the correct postal price on your envelope may result in applications not being
received and processed.
When we get your housing application:
We will let you know we have received it within three working days.
We will write to you within five working days of receiving it if we need any further information or proof.
We will contact you within ten working days if we need to arrange an interview at your home or nearest
Contact Centre.
We will contact you within twenty working days to confirm that your application is active or registered
(started to be used)
If we can not start your application within 20 working days, we will write and tell you why. The delay may be
because we need more information from you or another agency.
Confirmation of Application Receipt
I acknowledge receipt of your housing application received.
If we require any further information you will be contacted
within 5 working days. You will receive confirmation within 20
working days that your application is active or registered.
If you have any questions relating to your housing
application.
Page 25
PROVIDING ACCESS FOR ALL
If you need help understanding any of our documents or require a
larger print, audio tape copy or a translator to help you, we can
arrange this for you. Please contact us on the telephone numbers
at the bottom of the page:
POLISH
Jeeli potrzebuje Pan/i pomocy w rozumieniu tych dokumentw
lub chciaby je Pan/i otrzyma wikszym drukiem, na kasecie
audio lub skorzysta w tym celu z pomocy tumacza, jestemy to
Pastwu w stanie zapewni. Prosimy o kontakt pod numerami
telefonw na dole strony.
ITALIAN
Se avete bisogno di aiuto per capire qualsivoglia dei nostri
documenti o se li richiedete a caratteri grandi, o volete
copie registrate, o necessitate di un traduttore per aiutarvi,
noi possiamo organizzare tutto ci. Per favore
contattateci ai numeri di telefono che troverete in fondo a
questa pagina.
CHINESE
URDU
01246 242407 or 01246 242353.
Other Equalities information is available on our web site.
[Link] or by e-mail from [Link]@[Link]
Minicom:
01246 242450
Fax: 01246 242423
Page 26
