Housing Application & Housing Options Interview Form

Section 1
Date:
Customer Details
Title Forename Surname Gender
Date National
Other names used in
of Insurance
the last 5 years
Birth Number
Current Address (include house number, street, area, city and postcode)

Date
Date To
From
Correspondence Address, if different from above (include house number, street, area, city and postcode)

Home Phone Work Phone

Number Number
Mobile Email
Number Address

Current Housing Status

Owner-
LA Tenant Lodger PRS Tenant
Occupier
Shared Supported Tied
RSL Tenant
ownership Accommodation Accommodation
Non-Permanent Homeless Temporary Student
structure accommodation Accommodation

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Section 2
Consent to Share

What we will do with your information

This form explains how your personal information will be used as part of your assessment for housing. We are
committed to protecting your privacy. We try to meet the highest standards when collecting and using personal
information. We adhere to the requirements of the Data Protection Act 1998, when using and sharing personal
information. We are also registered on the public register of data controllers, with the Information
Commissioner's Office. Our Privacy Statement can be found on our website: https://www.maryhill.org.uk/about-
us/data-protection/privacy-policy.

Agreement to share your information

The Housing Options partners will collect and share your information with Glasgow City Council, other public
organisations and relevant agencies so we can understand your needs better, improve services and avoid
asking you for the same information more than once. This might include workers involved in your care, for
example your nurse, social worker, support worker, future housing providers or other relevant agency as
discussed with you.

The Housing Options partners, as landlords, will also collect and share your information for the purposes of
assessing your needs for housing and to develop a Common Housing Register (CHR). This will make it easier
for you to be considered for housing by a number of landlords and avoid you filling in separate registration forms
for each. This means when you fill in a housing registration form you agree to your information being shared
with other landlords, with other public organisations, organisations that handle public funds, social work services,
your support worker, your nurse and other relevant agency as discussed with you.

There may be occasions when there is sufficient concern about your or others safety or wellbeing, or for the
detection and prevention of crime that your information will be shared before your consent is given or even if you
do not agree to your information being shared.

I understand that information is held about me and agree that my personal information may be shared
with other relevant agencies and professionals where you consider it appropriate. I have had an
opportunity to discuss what this means.

I understand that the information I have given in this registration form is true. I also undertake to tell you
about people aged 16 years or over who live in my home.

Yes/No
I agree with this statement:

Name of Customer (print)

Signature of Customer

Signature of Advocate /
Representative (if required)

Interviewer’s Signature

Designation Date

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Section 3

Persons to be rehoused with you

Date of Gender Joint National Insurance

Person Name Relationship to you
Birth M/F Tenant Number
1 Yes/No

2 Yes/No

3 Yes/No

4 Yes/No

5 Yes/No

If any persons mentioned above are not living with you now, please detail below

Person
number
Current Address Reason for Living Apart
from
above

Applicant Person 1 Person 2 Person 3 Person 4 Person 5

Are you or anyone to be
rehoused with you on the Sex Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
Offenders Register?*

*This will not adversely affect how your application is assessed but will allow us to work with you and the
Sex Offenders Liaison Officer to identify the most appropriate offer of housing (Please refer to your
organisations guidance)

Emergency Contact Details/GP details

Name

Relationship

Address

Contact Telephone
Number
GP’s Name

GP’s Address

Contact Telephone
number

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Current Housing Provider

Name and address of

Landlord/Mortgage Provider

Contact Telephone Number

Date left or to leave Court Date (if relevant/known)

Would you consider
mediation?
Yes/No

Previous Addresses

Please list all of you and your partner’s previous addresses in the last five years: (Continue on a separate sheet if
necessary)

Address Tenant, Lodger, Date and Reason for Name of Landlord

Tied or Owner Leaving
Applicant
Partner

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Section 4

Why are you leaving or thinking about leaving your current accommodation?
(Please circle one main activity (M) and as many secondary activities (S) as required)

Housing

Social Work: Child

Dispute within household:
Abandonment M/S M/S Protection/Adult Protection M/S
violent/non violent
Disrepair: lack of
Affordability:
M/S amenities/below tolerable M/S Terminated accommodation M/S
rent/mortgage
standard
Anti-social/neighbour Eviction decree: illegal Tied accommodation/discharge
M/S M/S M/S
dispute eviction/notice to quit from forces
Asked to leave: care
M/S Lack of family support M/S Travellers M/S
of/sofa surfing
Other action by landlord:
Benefits (Housing permission to reside/wants
M/S M/S Under-occupation M/S
Benefit) to sell/Housing Benefit
shortfall
Breach of tenancy M/S Overcrowding M/S Wants own home M/S
Difficulty managing
M/S Rights to property M/S Repair issues M/S
home/needs support
Discharge from
M/S Separating partner M/S Aspirational move M/S
hospital/care/prison

Personal/Vulnerabilities

Addiction:
M/S Employment M/S Miscarriage M/S
alcohol/drugs
Benefits (DWP) Fire/flood/frost/
M/S M/S Older people M/S
emergency
Communication
M/S Isolation M/S Physical disability/mobility M/S
issues
Criminal Justice M/S Learning difficulty M/S Pregnancy M/S
Harassment/external
Risk of sexual/financial
Dependent Children M/S violence (religious, M/S M/S
exploitation
sexual, racial, ethnic)
Difficulty managing Medical/chronic ill
M/S M/S Vulnerability M/S
home/needs support health
Mental
Domestic abuse M/S illness/personality M/S
disorder

For the activities you have chosen above please provide details of why you need assistance or
are thinking of leaving current accommodation.

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 Section 5

Tenancy History and Housing Need

Has anyone living at the current address had an order for the
recovery of possession granted against them for reasons of anti- Yes/No
social behaviour in the last three years?
If yes, please give details of the Landlord who obtained the order

Is anyone living at the current address subject to an anti-social

Yes/No
behaviour order?
If yes, please give details of the order (Court granted, date granted, name of person)

Current Accommodation

Property Type e.g. Tenement,

When did you move in?
Multi-Storey Deck Access
How many bedrooms
Which floor do you live on?
are in this property?
How many people,
How many bedrooms do you
including you, live at
have exclusive use of?
this address?

Housing Requirements

Size of property required

Types of properties means tenements, multi-storey flats, deck access, terrace, cottage flat, semi-detached,
sheltered etc
Area(s) you would consider a List here any parts or streets in the area
Type of property requested*
property in that would be unsuitable

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*Please note that dogs are not allowed in multi-storey flats or any property served with a lift.

If you have chosen a multi-storey flat, what is the highest floor you would
accept? (write ‘any’ if any floor is acceptable)
If you have chosen a tenement, what is the highest floor you would accept?
(Write ‘any’ if any floor is acceptable)

Homeswapper

Some housing providers will automatically be registered for Home-swapper (Mutual Exchange
Scheme) should you wish to opt out of the scheme, please tick this box

Support

Some housing providers advertise vacant properties via the internet and/ or in weekly
publications which are available from local offices can be mailed to you. Would you
Yes/No
require help with expressing an interest in these advertisements?

If yes, what type of help do you think you need?

Your Needs

Tick where applicable

Applicant Person 1 Person 2 Person 3 Person 4 Person 5
Do you or anyone who is going to be
housed with you have any medical needs
that would be helped by a move to
another home? Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

If yes, please add details below in Health

/ Medical issues .

Do you or a family member require

sheltered housing?
Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

Do you or a family member need to move

to be near family or relatives to provide Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
or receive support?
Do you or a family member need to move
to be near a place of education?
Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
If yes, please provide details of which
area you require to move to:
Do you or a family member need to be
rehoused near your place of employment
or a place where you do voluntary work
Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
for 16 hours a week or more?

7
Health/Medical Issues

(For each person with a medical condition please state how their current accommodation affects their
health. Supporting information may be required before medical points can be awarded)

Current Support (All household members)

Agency Support provided Telephone Number

8
Section 6

Declaration

Are you an employee of this organisation? Yes/No

Are you related to an employee of this organisation? Yes/No

1. Name

If yes, please state 2. Position

3. Relationship

Are you a Management Committee Member? Yes/No

Are you related to a Management Committee Member? Yes/No

1 Name

If yes, please state 2 Position

3 Relationship
Declaration - To be signed by the applicant after completion of the form

I/We hereby declare that the information given on this form is, to the best of my/our knowledge and belief,
accurate and truthful.

I/We understand that if it is found that I/we have provided false information or misleading information to the
housing association; my/our application will be cancelled. Furthermore, I/we understand that the housing
association reserves the right to take legal action for the repossession of any tenancy granted on the basis of
deliberately providing the false information.

In addition I/we understand that in circumstances of threatening behaviour or verbal or physical abuse aimed
towards staff or committee members, the association reserves the right to withdraw an offer of housing or
suspend my/our application.

I/We authorise my/our landlord to obtain information on any tenancy I/we have held and to take up references
considered necessary and relevant to this application.

I/We understand that any false or misleading information, withholding information that is material to the
application now and at any time, may result in my application being cancelled, any offer of tenancy being
withdrawn or I may lose any tenancy I/we are granted.

Signed applicant Date

Signed joint
Date
applicant

Note: the completion of this form does not bind us to make an offer of housing accommodation available to the applicant(s).

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 Section 7:

Housing Options interview. (To be completed with the applicant)

Communication
Can you communicate in English? Yes/No Is an interpreter required? Yes/No
Do you require any assistance to
If yes, what type of help
communicate? (e.g. hearing/visual Yes/No
do you need?
impairments/literacy/numeracy)
Would you prefer to be interviewed by someone of the same sex as yourself? Yes/No

Do you have somewhere safe to stay tonight?

Yes/No
(If not make an appointment with GCC Casework Team)

Interview Details
Reference
Advisor
Number
Maryhill HA 0141 946
Location Telephone Number
2466
Reason for Visit
Tenancy Threatened with
Housing Advice Homeless
Advice Homelessness

Support (Identified – all household members): If any referrals made please detail below

Agency Date/Time Where With Whom

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Tenancy Sustainment/Prevention Activity
All Available Options Discussed (include discussion on rent from day one/in advance).

Accommodation Options Discussed

Adapted housing Mortgage to Rent Rent Deposit Scheme
Furnished accommodation Other RSL tenancy Shared ownership
GHA tenancy Owner occupation Sheltered housing
Homeswapper (Mutual Exchange) Private landlord Supported housing
Mid-market rent Remain in current accommodation Casework Team referral

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 Section 8
Financial Assessment
Household Income
Customer Net Salary/Wages
Partner Net Salary/Wages
Jobseeker’s Allowance
(detail of income/contribution
based)
Universal Credit (revert to
organisational policy for UC)
Income Support
Employment and Support
Allowance/Statutory Sick Pay
Incapacity Benefit
Working Tax Credit
Child Tax Credit
Child Benefit
Attendance Allowance
Disability Living Allowance
Personal Independence
Payment
State Pension
Occupational Pension
Pension Credit
Widow’s Pension
Maintenance/Child Support
Received
Any Other Income
Any Non-dependent
income/Contributions
Carer’s Allowance
Total Income
Savings
Employment/Benefit/Income
*Weekly/Fortnightly/ *Weekly/Fortnightly/
Household Expenditure
Four weekly/Monthly Four weekly/Monthly
Rent/Mortgage/Digs
£ (Including Bedroom Tax £
Priority Expenditure
deductions, Factor fees)
£ Council Tax £
Gas/Electricity (if interested
£ in reduced costs refer)
£
£ Court Fines £
£ Food £
£ School/Work Meals £
Loans/Credit & Store Cards/
£ Hire Purchase/Door step lenders
£
£ TV Licence £
£ TV Subscription £
House Insurance (Building &
£ Contents)
£
£ Internet/Home Telephone £
£ Mobile Telephone £
£ Clothing £
Pet Costs (Vets, food,
£ insurance)
£
£ Alcohol/tobacco/betting £
£ Maintenance Paid £
Child Care/after school
£ clubs/pocket money
£
Vehicle Costs (repayments, fuel,
£ road tax, insurance)
£
£ Travel expenses £
£ Any Other Expenses £
£
£ Total Expenditure £
£ Disposable Income £
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 Full time employed >30hrs Part-time employed <30hrs Student
Looking after family/home Permanently retired Unknown
Unemployed - seeking work Government work/training scheme Other
Self-employed Unable to work - disability/health Sanctioned by DWP

Employer name and address

If not employed, would you like to find

Referral made to Jobs and Business Yes/No
out more about your options for work, Yes/No
Glasgow
training, education or volunteering
Do you have a bank account? Yes/No Do you have access to the internet? Yes/No
Are you or have you ever been
sequestrated/bankrupt? Yes/No Have you ever been evicted from a tenancy? Yes/No

Yes/
No/
Are you in receipt of Universal Credit?
Applied
for

Section 9

Tenancy Sustainment/Prevention Activity

Please pick one main activity (M) and as many secondary activities (S) as required

Medical adaptation
Advice and information only M/S M/S

Advocacy
M/S Mortgage arrears intervention or rescue M/S
Conciliation Negotiation or legal advocacy for household to
M/S M/S
remain in private rented sector
Direct financial assistance – DHP &
M/S Other (please specify) M/S
Social Fund
Direct financial assistance – Other Provision of independent financial advice
M/S M/S
e.g. Transitional Support Fund
Furniture Assistance
M/S Referred to Homeless Casework Team M/S
Resolving arrears in private rented sector
Health M/S M/S
M/S
Homeswapper/Mutual Exchange Resolving arrears in social sector M/S
M/S
Housing Support Sanctuary scheme/similar for domestic violence M/S
Jobs & Business Glasgow
M/S Shelter M/S
M/S Social Care
Liaison with landlord M/S
Supported temporary accommodation
Local allocation policy e.g.
M/S M/S
management transfer, sep partner
Mediation
M/S

Housing Options Feedback

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 To assist with the development of Housing Options Services you may be contacted
for feedback. If you do not want to participate please tick box

Pre Housing Application

Where the customer has no priority need please ensure that you ask the following question –

We have discussed your options and your chances of housing with this
organisation is very low. We would advise you to pursue the options
detailed in your personal plan.

Do you still wish to progress to an application for housing? Yes/No

Signature of
Date
Customer

Form Loaded By:

Date Ref No.

Interview
Completed By Signed
(Advisor’s Name)

For official use only

History of Does the Customer have the
Was Representation/
Yes/No Violence/Alert On Yes/No Right to Receive Public Yes/No
Advocacy Offered
System Assistance e.g. DWP benefits

Sub Area Studio 2 3 4 5

APT APT AP APT

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 T
Skirsa Tenements: 5-8 Skirsa Court

Lochburn Tenements : 4&12 Cadder Gr, 9-23 Cadder Pl, 26-30 &67-69
Cadder Rd,
4-20 Langa Gr, 3&7 Langa St. 26-46 Lochburn Cres, 4&12 Lochburn Gr
Lochburn Cottages: 4-86 Glenburn St,
9-81 Knowetap St, 15-91 Thornton St
North High Flats: (3 Apts can be underoccupied)
29, 71, 155 Glenavon Road
North Mini Multis: 266-276 Cumlodden Dr,4-120 Fearnmore Road,1
Lyndale Place, 5 Lyndale Road,545 Sandbank Street,200-220 Shiskine
Dr - (3 Apts can be underoccupied)
North Cottages: 4-52 Cottar St, 8-29 Cranbrooke Dr, 173-201
Cumlodden Dr, 7-46 Duncombe St, 6-26 Dunure St, 20-119 Duncruin St,
29-63 Fingal St, 7-20 Gillhill St, 31&33 Campbell St, 1-101 McLaren
Cres, 171 Shiskine Dr, 15-199 Thornton St, 2B-2M Viewmount Dr, 64
Whitelaw St
North Tenements : 1-25 Celtic St, 2&21 Cottar St, 3-5 Duart St, 2-110
Fingal St, 1&22 Gillhill St, 205-239 Sandbank St, 210-230 Sandbank St,
1979-1979 Maryhill Rd, 175-199 Thornton St, 2A&2P Viewmount Dr, 30-
62 Whitelaw St
Cumlodden Estate: 20-81 & 204-276 Cumlodden Dr, 1666-1700
Maryhill Rd, 2-44 Sandbank Terr
Gairbraid: 5-45 Balfour St, 45-155 Burnhouse St, 5-82 Guthrie St, 64-
151Gairbraid Ave, 6-46 Gairbraid Pl, 96-106Kelvindale Rd, 7 Lochburn
Rd,1490-1534 Maryhill Rd
Hathaway : 7-67 Hathaway Lane, 1064-1180 Maryhill Road

Oran : 1 Avenuepark St, 1001-1043 Maryhill Rd, 43 Mingarry St, 1-15

Oran Gdns, 11-49 Oran Gate, 221 Queen Margaret Dr, 88-96 Sanda
Street
Garrioch: 5-45 Amisfield St, 147 Garrioch Rd, 38-86 Shakespeare St,
83-109 Stratford St
Craigmont/Shawpark: 9-71 Craigmont Dr, 11 Craigmont St, 1296-1428
Maryhill Rd, 6-40 Shawpark St
Eastpark: 3-13 Bilsland Dr, 4-16 Leyden Gardens, 2-31 Leyden St, 970-
1034 Maryhill Rd, 8-14 Sandfield St, 673-756 Bilsland Dr
Ruchill Tenements: 257-427 Bilsland Dr, 23-43 Mayfield St, 47-313
Ruchill St, 12-52 Shannon Street
Ruchill Cottages: 1-186 Brassey Street, 2-72 Currie St, 1-195 Curzon
St, 1-114 Leighton St243 Shuna St
Ruchill (Parkhill): 1-19 Bilsland Crt, 2-14 Hazlitt Gardens, 1-32 Hazlitt
Pl, 12-56 Hazlitt St, 1-31 Parkbrae Dr, 2-23 Parkbrae Gdns, 2-36
Parkbrae Gate, 2-26 Parkbrae Lane
Ruchill Park: 10-16 Hugo St, 4-20 Ruchill Pl, 90-136 Ruchill St

Retirement Housing: 1-12 Shiskine Place, 35-68 Oran Place

Rothes Drive:Caldercuilt Grove, Caldercuilt Road and Rothes Drive

Cowal Road
Smeaton St (New Build 2024)
Maryhill Locks – 2 – 16 Collina Street, 2 – 42 Collina Quadrant, 2 – 33 Stirrat
Place, 1 -10 Stirrat Place, 3 – 29 Niven Street, 69 Guthrie Street

MARYHILL HOUSING LETTING SUB AREAS:

15