The Regulatory Reform (Housing Assistance)

(England and Wales) Order 2002

APPLICATION FOR DISCRETIONARY GRANT

1. Name and Address

1.1 Please provide details of the applicant:

Kim Evans
Full Name…………………………………………………….. For Arya Evans DoB - 20/08/2015

Title: Mrs
Mr/Mrs/Miss/Ms/Other (Please specify) ……………………….
Date of Birth…………………………………………………………………………..
2 Ashfield Crescent
Address………………..…………………………………………………………………
Chester
……………………………………………………………………………
…………………………………………………………………………………
CH1 5AU
Postcode…………………………………………………………………….……………
Mum - 077323 80659 / Dad - 07584 124028
Telephone No…………………………………………………………………………

1.2 If someone else is handling this application on your behalf, please give the
name, address and telephone number of the person to be contacted about this
application.

Homekey+ HIA
Full Name:……………………………………………………………………………………
Title: Mr/Mrs/Miss/Ms/Other (Please specify)……………………………
PO Box 235
Address:…………………………………………………………………………………
CH34 9FB
……………………………………………………………………………………………
…….………………………………………………………………………………………
07923 438659 - Caseworker - Deanna Bradshaw
Telephone No……………………………………………………………………………

2. Property Details

2.1 Please give the address of the property for which you are seeking grant
As above 1.1
assistance:………………………………………………………………………………

……………………………………………………………………………………………

2.2 What date was the property constructed (please tick)

 Pre 1920  1920-1945  1946-1979  post 1979 

3. Ownership Details

Do you (alone or jointly with others) own the freehold of the property or hold a
tenancy of it with at least 5 years still to run? (Please tick  as appropriate)
Yes 

Please indicate which interest you own (delete as appropriate).

Freehold/Tenancy with at least 5 years still to run

If you hold the interest jointly with other people, please give the names and
addresses of your co-owners:

Property is rented from Landlord Mr Roy Dolby

…………………………………………………………………………………………
37A Mayfield Road, Blacon, Chester CH1 5HY
…………………………………………………………………………………………
tel 07723 374234. Has consented to works.
……………………………………………………………………………………………

4. Application Type

4.1 Is this application in connection with another home assistance grant/loan

application?

Yes  No 

4.2 If yes, please tick which type if known:

Mandatory DFG  Decent Homes Loan  Empty Property Grant  Other 

5. Who will carry out the works?

5.1 Will you or a member of your family carry out the works?

Yes  No 

5.2 Do you agree for any grant approval to be paid to your builder (either directly or
by cheque made out to your builder)?

Yes  No 

6. Details of Works involved

6.1 Please attach an estimate from your contractor and briefly describe the works to
be carried out at the premises.

Please refer to schedule from TO

…………………………………………………………………………………………..

……………………………………………………………………………………………

…………………………………………………………………………………………..

6.2 Have you already begun or finished the works for which you are applying for
grant?

- begun the works? Yes  No 

- finished the works? Yes  No 

7. Preliminary or ancillary services and charges

7.1 Please give details of any preliminary or ancillary services or charges which you
wish to have considered for assistance:

Please refer to provisional invoice for main DFG

……………………………………………………………………………………………

……………………………………………………………………………………………

……………………………………………………………………………………………

8. Planning permission and building regulations approval

8.1 Have you applied for planning permission for the works? Yes  No 

Please give the date, reference number and outcome of your application:
See DFG app
Date: ……………………………….. Reference number: ……………………

Outcome (please delete as appropriate): granted/refused/no decision yet

8.2 Have you applied for building regulations approval: Yes  No 

Outcome (please delete as appropriate): granted/refused/no decision yet

9. Details of funding required

9.1 Reason for expenditure
Shortfall £33,249.20
…………………………………………………………………………………………………………
Alison agreed 50% to be covered by:
Discretionary application = £16,624.60
…………………………………………………………………………………………………………
50% to be covered by customer = £16,624.60
…………………………………………………………………………………………………………

9.2 Please include details of any enquiries and responses from charitable or other
sources of funding eg loan applications:
…………………………………………………………………………………………….
NA
…………………………………………………………………………………………….

……………………………………………………………………………………………

……………………………………………………………………………………………

9.3. Please give any additional information in support of your application:

Works are required urgently for Miss Evans.
……………………………………………………………………………………………
Would be unable to secure finding of this size via charaties.
……………………………………………………………………………………………

……………………………………………………………………………………………

10. Documents submitted with your application

10.1 Please indicate which documents you are enclosing with your application:

Yes No
(a) Particulars of any preliminary and ancillary services and
charges  

(b) A completed proof of title certificate (lands consent)  

(c) A schedule of the proposed work and plans  

(d) A contractor’s estimate for the works  

(e) Information in support of your application from your

Occupational Therapist if appropriate   NA

(f) Evidence of refusal of assistance from two loan companies   NA

(g) Financial Information form   NA

Declaration

Warning: If you knowingly make a false statement you may be liable to

prosecution.

I declare that to the best of my knowledge, information and belief the information
I have given above is correct. I am aware that I may be required to make a
financial contribution in the event that this application is approved for a lower
amount than that applied for.

I can also confirm that I agree to be bound by the conditions that may be
attached to any grant approval. If your application is for funding to top up a
Disabled Facilities Grant, the conditions applied to this application will be the
same as those applied to Disabled Facilities Grants, with the exception of the
repayment condition which is as follows:

The full amount of discretionary grant approved may be repayable if the property
is sold within 10 years of the certified date of completion of the works. We will
ask you to repay all or some of this grant if we are satisfied that it is reasonable
to do so having considered the following criteria:

a) The extent to which you would suffer financial hardship if the grant
was reclaimed;

b) Whether the disposal of the property was to enable you, or the disabled
person, to take up employment, or change the location of their employment;

c) Whether the disposal of the property is made for reasons of your, or the
disabled person’s, physical or mental health or well being: or

d) Whether the disposal is made to enable you or the disabled person, to live
with, or near any person who will provide care for you or the disabled person by
reason of disability.

No grant will be repayable if you, or the disabled person, die within the 10 year
repayment period.

X
Signature: …………………………………………………………

X
Date: ………………………………………………………………..