INTERIM

*HOMELESSLEDGER+K53696
+D*

APPLICATION FOR ASSISTANCE

UNDER THE HOUSING ACT 1996
The law tells us which homeless people we are allowed to help and what kind of help we can
offer. It is important that you answer all the questions on this form so that we may decide how to
help you.

What the law says the council must do:

We must make enquiries to establish whether or not you:
a) are eligible for housing assistance under the provisions of the Housing Act, 1996
(Part VII, Section 185);
b) are homeless or soon to become homeless (that is, threatened with homelessness);
c) are in priority need for housing – this means being pregnant, having dependent children,
substantial medical problems, being elderly etc;
d) are homeless or threatened with homelessness through your own fault – this is called being
‘intentionally homeless’;
e) have a local connection with this or any other council.

In some circumstances, the council may also take reasonable steps to prevent loss or damage to
your personal property, e.g. by placing your furniture into storage.

What the law says you must do:

You must give us the information we need and you must tell us the truth. You will be liable for
prosecution for a criminal offence if you:
a) give false information with the intent of misleading the council to believe that you are entitled to
accommodation or assistance,
and/or you
b) withhold information which the council needs to process your application,
and/or you
c) don’t tell the council as soon as possible of any changes in your circumstances which are relevant
to your application and have occurred before the council gives you a decision on your application.

If you are an employee of the council and you give false information or withhold information or fail
to notify the council of any change in your circumstances, you will be liable for disciplinary action
under the council’s procedure as well as being liable for prosecution for a criminal offence.
Furthermore, there is a maximum fine of £5,000 payable if you are found guilty of such an offence.

The council must protect the public funds it administers and so may use the information that you
give in this application to prevent and detect fraud. We may also share information with other
organisations which administer public funds.
 Section 1
Applicants and/or joint applicants must be 16 years or over
Please give details of ALL the people you wish to include in your application form.
The answers supplied and submitted as part of your Housing Option Enquiry will form part of
your Part VII Housing Assistance Application under the Housing Act 1996

Applicant’s name
Address
Date of Birth

Please insert your Saffron Number:

Housing Option Form
reference number:

Q3 Do you have a Care, Custody or a Residence Order and/or Parental Agreement YES NO
in respect of the children listed?
If YES, please give the names of the children and supply relevant documents

Q6 Who should we contact in an emergency?

Name: Relationship to you:

Address: Email:

Telephone: Mobile:

Q7 Do you have any adult children, brothers, sisters, parents or other close relatives living in the
borough of Wandsworth? If so, please give details
Name Address Relationship to How long have they
Applicant lived in the
borough?
 Section 2
IT IS IMPORTANT THAT YOU ANSWER ALL OF THE QUESTIONS IN THIS SECTION

Asylum and Immigration legislation places a duty on local authorities to establish whether
applicants are eligible for housing within the terms of the Housing Act 1996 as amended. It
is necessary, therefore, for you to complete the questions below.

Q1 Please give details of your current or last employment

To From Name of last employer Contact details of employer

Q2 Have you failed the Habitual Residence Test as applied by the Department of Work and Pensions
(DWP) or any local authority?
Please tick relevant box(es)
YES NO

Who gave you that decision?

Name Organisation Contact Details
 Section 3
3A – Applicant

In relation to your address history previously provided, please tell us more about your housing
history (please complete with your addresses for the last 5 years starting with your current address)
Q1 Address:

Name of the person who is asking/asked

you to leave:
Their address:

Telephone number:
Name of the landlord (if different from
the person asking you to leave):
Landlord’s address and telephone number
(if different from the person asking you to
leave):
How much rent do/did you pay? Weekly Monthly

What rooms do/did you have sole use of?

What rooms do/did you share (other than

with a member of your household)?

Q1 Address:

Name of the person who is asking/asked

you to leave:
Their address:

Telephone number:
Name of the landlord (if different from
the person asking you to leave):
Landlord’s address and telephone number
(if different from the person asking you to
leave):
How much rent did you pay? Weekly Monthly

What rooms did you have sole use of?

What rooms did you share (other than

with a member of your household)?
Q1 Address:

Name of the person who is asking/asked

you to leave:
Their address:

Telephone number:
Name of the landlord (if different from
the person asking you to leave):
Landlord’s address and telephone number
(if different from the person asking you to
leave):
How much rent did you pay? Weekly Monthly

What rooms did you have sole use of?

What rooms did you share (other than

with a member of your household)?

Q1 Address:

Name of the person who is asking/asked

you to leave:
Their address:

Telephone number:
Name of the landlord (if different from
the person asking you to leave):
Landlord’s address and telephone number
(if different from the person asking you to
leave):
How much rent did you pay? Weekly Monthly

What rooms did you have sole use of?

What rooms did you share (other than

with a member of your household)?

Please continue on a separate sheet if necessary.

Q1 Address:

Name of the person who is asking/asked

you to leave:
Their address:

Telephone number:
Name of the landlord (if different from
the person asking you to leave):
Landlord’s address and telephone number
(if different from the person asking you to
leave):
How much rent did you pay? Weekly Monthly

What rooms did you have sole use of?

What rooms did you share (other than

with a member of your household)?

Q1 Address:

Name of the person who is asking/asked

you to leave:
Their address:

Telephone number:
Name of the landlord (if different from
the person asking you to leave):
Landlord’s address and telephone number
(if different from the person asking you to
leave):
How much rent did you pay? Weekly Monthly

What rooms did you have sole use of?

What rooms did you share (other than

with a member of your household)?

Please continue on a separate sheet if necessary.

 Section 4
Q1 Have you ever approached this or any other council with regard to YES NO
homelessness?
If YES, please give details
Address at time of application:

Date of application:
What is/was the outcome of the
application:

Name of council:
Reference No.

Q2 Have you ever registered on the housing register of this or any other council at YES NO
any other time?
If YES, please give details
Address at time of application:

Date of application:
What is/was the outcome of the
application:

Name of council:
Reference No. Points:

Q3 Have you approached anyone else for housing at any time? (e.g. housing YES NO
associations, registered social landlord, private landlord/agency)
If SO, please give details below.
Q4 If you have ever owned or part owned a property here or abroad please provide the following
information:
Address of property:

Purchase price:
Dates of ownership: From To
Monthly repayments:
Mortgage account number:
Amount of arrears outstanding (if applicable):
Name and address of lender:

Reason for leaving (if applicable):

Has this property been sold? (tick applicable) YES NO
Reason for selling this property?
How much did you sell your property for?
Date of sale:
Name and address of solicitor acting in the sale:

Please continue on a separate sheet if necessary.

 Section 5
Q1 Have you spent a period of time in care? YES NO

Which social services

authority was responsible for
you?

Dates between which you From To

were in care:

Q2 Have you ever been imprisoned (whether on conviction or remand)? YES NO

If YES, please state why, when and where you were in prison (if not previously stated.)

Address of Prison

Dates: From To
Reason
Address of Prison

Dates: From To
Reason
Address of Prison

Dates: From To
Reason

Q3 Do you have a probation officer/social worker/solicitor/other support worker?

If so, please give details below (please tick relevant box(es)
PO SW Solicitor Other (Please specify)
Name of worker:

Address: Address:

Telephone number: Telephone number:

Email: Email:
Name of organisation: Name of organisation:

Please continue on a separate sheet if necessary.

 Section 6
Q1 In the last five years have you left accommodation or been afraid to YES NO
remain at accommodation because of domestic violence, other
violence, harassment or fear of violence/harassment? If YES, please
give the following details
The full name of the person you were afraid of:

Is he/she related to you: YES NO

If YES, please state their relationship to you:
What is/was their address:
Why do/did you feel at risk:
Do you consider yourself to be still at risk from YES NO
this person:
When was the last incident (date):
Were the police called to any incident:
If YES, please give details (including crime reference number(s), dates, times, police officers names
(if known)

Are you still at risk from any other person: YES NO

Who are you at risk or afraid of:

What is their address?

Relationship to you

Q2 Has any incident(s) been discussed with a solicitor? YES NO

If YES, please give details below
Name of firm:
Email:
Address:
Has any court order/injunction been obtained against this person? YES NO
If YES, please give details below (please provide documents at your next
interview)
Date(s) granted:
Name of court:
Court reference number:
Is the court order/injunction still in force? YES NO
If YES, when does it expire? Date:
Q3 Has this/these incident(s) been discussed with anyone else? (e.g. a YES NO
social worker, GP, health visitor, hospital, victim support, housing
officer.)
If YES, please give details of who you have talked to and their contact
details below
Full name:
Address:

Telephone number:
Email:
Has any affidavit or statement been made for a solicitor, a court or YES NO
other agency in relation to incidents or fear of violence? (Please note
you will be asked to provide documentary evidence)
 Section 7 Medical Information
Please provide details about your GP and any health conditions

Q1 Doctor’s name:

Doctor’s address:

Telephone:
When did you register with this doctor? If
with in the last 5 years, please provide
details of your previous doctor
Previous Doctor’s name:
Previous Doctor’s address:
Telephone:
Name and address of your health visitor
(if you have one)

Please provide details of any hospital or clinic that you currently attend.

Q3 Name of hospital/clinic:

Address:

Hospital number, doctor and/or

department attended:
Dates of attendance:

Q3 Name of hospital/clinic:

Address:

Hospital number, doctor and/or

department attended:
Dates of attendance:

Q3 Medical Condition(s):
 Name of hospital/clinic:

Address:

Hospital number, doctor and/or

department attended:
Dates of attendance:

Please continue on a separate sheet if necessary.

Q4 Do you currently suffer from ill health which you think is relevant to your YES NO
current or future housing needs?

We will send a separate Medical Assessment Form where appropriate and required. You
do not need to send a separate doctor’s letter.
 Section 8 Income details
Q3 Do you claim any welfare benefits? YES NO
If YES, please give details

Q4 Do you get maintenance from an ex-partner? YES NO

If YES, please give details of how much and how often it is paid

Q5 Do you get a private pension? YES NO

If YES, please give details of how much and how often it is paid

Q6 Do you have any investments, e.g. shares, bonds? YES NO

If YES, please state the amount and the types of investments

Q7 Do you have any other income? YES NO

If YES, please state the amount and where it comes from
Q8 Do you have any bank or building society accounts, including YES NO
other saving accounts?
If YES, please state the name of the bank/building society, branch
and account number for each account.
 Section 9
The council needs to ensure that all accommodation is allocated fairly in accordance with the
law. If you are related to, or have a close relationship with a councillor or employee of the
council please give details below. Any declaration made will not affect how your application is
assessed.

Q1 Are you, to your knowledge related to any YES NO

employee of Wandsworth Council?
If YES, please give details
Name of the councillor/employee:

Relationship(s) to councillor/employee:

Q2 Are you employed by Wandsworth Council? YES NO

If YES, please give details
 Section 11 Other Information
Q1 Is there any other information you wish to provide in support of your application?
If so, please give information below
Section 12
Co-operation between the housing and community services department and the education and
social services department.

The law requires that the council’s housing and community services and education and social
services departments work together on certain applications. For example, if the housing and
community services department concludes that it is unable to provide you with
accommodation under the provisions of the homelessness legislation (e.g. you are found
ineligible for assistance or intentionally homeless and you have dependant children), you can,
with your consent, be referred to the council’s education and social services department for
advice.

You will be referred if you provide written consent to the council. Please sign the consent for
below if you would like to be referred to the education and social services department in the
event of the housing and community services department being unable to assist you.

I/we do/do not consent the disclosure of the relevant facts of my/our case to the education and
social services department.
Applicant Signed: Print: Date:

Please note: Should your application for assistance under PartVII of the Housing Act not be
accepted, you are still entitled to make an application, under Part VI of the Act, to the council’s
General Needs Queue.

If you are 55 years and over, are you interested in sheltered YES NO
housing?
Section C

Authorisation to Disclose Information

The council need your permission to make certain enquiries to confirm that you are eligible for
assistance, homeless, have a ‘priority need’ for help with your housing and did not become
homeless ‘intentionally’.
All replies to these enquiries will be treated confidentially, provided that you have not attempted
to mislead the council.
I have applied to the London Borough of Wandsworth for help with housing. I authorise you to
provide the council with the assistance or the information they need to complete their enquiries
under section 184 of the Housing Act 1996 (Part vii). I realise that this form may be photocopied
and used to obtain information.
If you seek to obtain accommodation by making a false or misleading statement, by withholding
information reasonably requested, or by failing to inform the council of a material change in your
circumstances, this could result in the loss of your accommodation and you may be prosecuted.

Signature of applicant: Date:

Print: Date:
Witnessed by (council officer): Date:

Authorisation to Disclose Information (Other Household Members)

The council need your permission to make certain enquiries into your inclusion in this application.
All replies to these enquiries will be treated confidentially, provided that you have not attempted
to mislead the council.
I authorise you to provide the council with the assistance or the information they need to
complete their enquiries under section 184 of the Housing Act 1996 (Part vii). I realise that this
form may be photocopied and used to obtain information.
If you seek to obtain accommodation by making a false or misleading statement, by withholding
information reasonably requested, or by failing to inform the council of a material change in your
circumstances, this could result in the loss of your accommodation and you may be prosecuted.
Declaration & Authority
Please read the following important information BEFORE signing your application for housing
assistance.

1) The attached pages form the basis of my/our application for housing assistance
under provisions of the Housing Act Part VI and Part VII, 1996. I/we confirm that
the applicant/joint applicant has read the information in this form.
2) I/we understand that it is a criminal offence under sections 171 and 214 of the
Housing Act 1996 to knowingly or recklessly make a false statement or knowingly
withhold information that the council has reasonably required him/her to give in
order to assess their application. Anyone found guilty of offences under these
sections, may be liable to a fine of up to £5,000. I/we understand that if I/we
obtain accommodation by making a false or misleading statement, by withholding
information reasonably requested, or by failing to inform the council of a material
change in my/our circumstances, this could result in the loss of my/our
accommodation and I/we may be prosecuted.
3) I/we believe that the information I/we have given is correct and complete to the
best of my/our knowledge and, in making this application, I/we have not withheld
any information which has any bearing on my/our homelessness or my/our
entitlement to housing assistance by the council, under Part VI or Part VII of the
Housing Act, 1996.
4) I/we will keep the council informed of any change in my/our circumstances; I/we
will do this in writing.
5) I/we agree that in order to provide me/us with suitable accommodation, the
council may pass relevant information to third parties, including housing
associations, registered social landlords, medical practitioners and agencies
working in partnership with the council. I/we agree to being contacted by any
agency working in partnership with the council in relation to my/our housing
application.
6) If I/we am/are an employee of the council and give false information or withhold
information or fail to notify the council of changes in my/our circumstances, I/we
understand that I/we will be liable for disciplinary action under the council’s
procedures as well as being liable for prosecution for any criminal offence I/we
may have committed.
7) IMPORTANT: This 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.

Signature of applicant: Date:

Print: Date:
Witnessed by (council officer): Date: