Title
Mr
Miss
Ms
Mrs
Dr
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
National Insurance Number
*
Relationship Status
Single
Married
Divorced
Widowed
Other
Ethnic Origin
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Telephone No.
Mobile Telephone No.
Email Address
Which scheme/s would you like to live at?
*
If your choice is Moseley and/ or Sutton Coldfield, please state floor preference
Ground Floor
First Floor
No Preference
Number of bedrooms required (Quinton only)
*
If only requested 2 bed, please supply reason why
Please indicate the main reasons for wanting accommodation (tick applicable)
Please select your current accommodation status
Council tenant
Housing association
Private rent
Tied home or renting with job
Own or buying
Jointly owned
Living with family
Supported housing
Sheltered or retirement housing
Residential care home
Hospital
Staying with friends
Homeless
Other
How long have you lived at your current address? (if less than 5 years, please provide your previous addresses.)
Property type (3 bed house, 2 bed 1st floor flat etc)
Previous address/s details for last 5 years (please supply full address and dates at address)
Are you or have you ever been a resident of Birmingham? If yes, please provide dates
If you do not currently live in Birmingham, please state your reason for moving to Birmingham?
Do you have any immediate family or friends living in the area?
Yes
No
Do you have a relative/friend living at Lench’s Trust? If yes, please state their details and the Scheme name)
Has your landlord given you Notice to vacate? If yes, please supply date and reason. (Written proof will be required at home assessment)
*
Have you ever been evicted or served written notice from a previous tenancy? If yes, supply details, including address, landlord, dates and reasons.
Please provide your landlord’s contact details: If we offer you a property, we will request a Landlord reference. This relates to your current rent account, any anti-social behaviour, tenancy breaches and property condition. (Approval will be dependent on a satisfactory reference)
Do you or your partner currently own a property either in the UK or abroad? If yes, give details.
*
Did you or your partner own a home that has subsequently been sold or gifted to your children? If yes, give details.
Are you claiming Housing Benefit/ Universal credit?
Yes
No
If yes, please supply amount and payment frequency (proof will be required at home assessment)
Do you own a car?
Yes
No
Do you own a pet? (If yes, please state type, breed & age)
GP Name
First Name
Last Name
GP Address and Contact details
Names and contact of any involved support or health professional agency (CPN, Social Worker, age concern, probation officer etc)
First Name
Last Name
Address
Phone
(###)
###
####
Email
Relationship
First Name
Last Name
Address
Phone
(###)
###
####
Email
Relationship
Do you confirm that Lench’s Trust may contact your next of kin and/or Emergency contact when necessary using the information you have provided above.
Have you or the joint applicant been convicted of ‘offences against the person’, meaning you have committed a crime causing direct physical harm or force being applied to another person, including but not limited to fatal or sexual offences, assault and injury or ‘crimes against property’, including arson, theft, burglary, robbery and fraud. Please tell us if any of these are ‘spent’ under the Rehabilitation o Offenders Act 1974
Take home pay (wages)
State Pension/ Pension Credit
Text
Do you have a bank account/s?
Saving, investments, ISA's, any other (list type and amount)
Name & Amount
Owned Property in UK or abroad (please specify)
Property address & Equity £
Please tick any boxes which apply to either applicant’s current health issues:
Please give details and list any further health, disability or mobility problems, also list any aids and adaptations you have or require in your new home as determined by your GP or Occupational Therapist.
Please list all current medication
If you/joint applicant receives care or domestic calls, please give details below of your current package (including hours per week):
Please give details of your current care/ domestic providers:
If you do not currently receive a care or domestic package but would like us to provide one (William Lench Court only) please state what you would require: (Please refer to the Care leaflet.)
Please give below the reasons why you need to move any further information you may wish to give in support of your application (add additional information at the end of the application if required)
*
How did you hear about Lench’s Trust?
Friends/ family
Online media (website, social media etc.)
Word of mouth
Health professionals
Birmingham City Council
Other
I/we declare that as far as I/we know the answers I/we have given on this form are true and I/we understand that if I/we have knowingly given false answers this may be ground for setting aside an appointment, whereby i/we would lose my/our home. I/we declare that I/we have no other bank accounts, savings, investments, property or any other monetary value than I/we have not listed on this form
*
Completion of Form
If this form has been completed by someone other than yourself, please complete the following:
