Change of Circumstances

Name (required):
UPIN (required):
Date of Birth (required):
 
Please confirm of update your current contact details
Telephone:
Home
Work
Mobile
Email:
 
Please tick the appropriate box (only answer the relevant questions)
 

Remove my name from the list
If you would like to remove your name from the list, tick the box and

Change of address
If you have moved address tick the box and - You now need to complete a new online application
Add an adult
(proof required for additional adult only)
Removing a person from application
Change of name for existing applicant
(proof required)
Adding a child or baby due
(proof required)
 
Please enter person details that relate to the change of circumstances.
Forename Surname Sex DOB Relationship to you NI Number
if applicable		 Do they live at the
same address as you
(please select if applicable)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
 
Is anyone on the application form pregnant?
Name
Date Baby Due (Please provide proof of pregnancy showing date baby due)
Contact address if different
   
If you are in hospital or residential care and are unable to return to your home due to serious medical condition Yes No
(if yes, please provide written proof from your
GP, ward sister or care home matron)
Do you have to leave your home due to a Closing Order? Yes No
Are you likely to lose your accommodation in the next 28 days? Yes No
If yes to the above, are you Working with Stafford Borough Councils Housing Options team? Yes No
Are you in temporary supported accommodation and been given a move on date? Yes No
Do you have to leave home due to a Compulsory Purchase order? Yes No
(If yes you will need to provide proof)
Have you been assessed by Stafford Borough Council as living in Insanitary Accommodation? Yes No
   
Are you applying for welfare priority due to one of the following. We will be required to verify the welfare priority, this will then be awarded by the Housing Choices manager or Neighbourhood Services Manager
You are a victim of domestic violence and your personal safety is seriously threatened Yes No
You are a victim of harassment and your personal safety is seriously threatened Yes No
You need to move from one town to another to be nearer schooling, work or
support and there is no bus routes to accommodate your travel requirements. 		Yes No

There is a serious housing need which is threatening your ability to remain living independently in the community.

 Yes No
 
If you are living in a House of Multiple Occupation or a B&B or Hostel accommodation do you have the following facilities (please tick all boxes that apply)?
Your own living room
(Bedsit room counts as a living room)		 Yes No Shared
Your own kitchen
(A cooker in a bedsitting room does not count as a kitchen. If this is your only method of cooking answer no)		 Yes No Shared
Electricity supply to your property
(this is not applicable if the supply has been disconnected due to non-payment)		 Yes No
Your own W.C. Yes No Shared
A water supply, hot and cold water Yes No
Is there a heating supply to the property (this is not applicable if the supply has been disconnected due to non-payment) Yes No
   
If your income has changed please give details of your weekly income including all benefits.
Income, benefits and pensions You Your partner
 
   

Health and Disability

  
Do you or anyone included in your application have any medical condition or disability which is made worse by your present housing situation? Yes No
Do you or anyone else on the application have a long-term disability that prevents you/them from carrying out normal day to day activities? Yes No
  Applicant 1 Applicant 2
Full name of whoever has the medical condition or disability
What is the nature of the condition or disability
What is the disability?
Blindness or sight loss Yes No
Mobility problems including the use of wheelchair or mobility scooter Yes No
Deaf or hearing loss Yes No
Deaf without speech Yes No
If you have an advocate please provide contact details including name and telephone number
Learning difficulties/Dyslexia Yes No
Mental health issues Yes No
Prefer not to answer about disabilities or medical conditions Yes No
Do you need information to be provided in any of the following ways? Audio CD
Audio tape
Email
Large print
Other
If other please indicate
   
In your present accommodation are you able to:
  Yes unaided Yes with aids and adaptations or with support No With difficulty Does not apply
Climb stairs
Reach the toilet
Reach the bathroom facilities
Reach your bedroom
Use the kitchen/cooking facilities
Personal Care eg Bathing, dressing, cleaning or laundry
Manage financial matters eg Paying bills
Go shopping
   
Do you have any of the following adaptations within your current home?
  Yes No Not applicable
Ramps to the front door
Ramps to the back door
Grab rails to bath
Grab rails to w.c.
Shower unit
Stair lift
Low level kitchen units
Wider doorways
Other(s) please state
   
Do you or does anyone in your household receive any of the support? Yes No
Does the medical condition/disability require you/them to have a carer or receive support from others? Yes No
If yes who is providing this?
Please provide the name and telephone number or email of the person providing support
Do you require your carer to stay overnight? Yes No

Please provide details of the type of care being provided and the distance the carer has to travel if applicable.

If you have a registered carer proof of your carer's allowance will be required.
   
SARH have a Mutual Exchange List which is on public display at The Rurals for those tenants wishing to find an exchange between other SARH or RSL (housing association tenants) and Council Tenants
I am interested in being registered on the Mutual Exchange List (Please tick if interested)
(Please note that this will involve having your details on public display in Stafford & Rural Homes' offices and on the website and a form will be sent to you for completion.)
   
   

Other Details That May Support Your Application
Any other factors you wish to make us aware of when assessing your application
Have you, or anyone listed in this application, been convicted of any offence other than those referred as 'spent' under the Rehabilitation of Offenders Act 1974?
  Yes No
Are you, or anyone listed on this application, required to notify the police in accordance with Section 1 of the Sex Offenders Act 1997?
  Yes No
Name of police office
   

Further information

  
If you wish to add any further information to support your application, please use the space below
 
   
Please indicate if you would like information on
Housing Associations in Stafford Borough
Shared Ownership Schemes
Homebuy Schemes
Private rented Accommodation
Hostels
   

Update your references
You are required to supply two references, if you would like change the references from your original application please download new reference letters. One should be from your current or previous landlord if this is applicable to your circumstances. Other suggestions for references could be from your employer present or past or from a professional person who knows you.
WE DO NOT ACCEPT REFERENCES FROM FRIENDS OR FAMILY MEMBERS

Please ensure you complete all parts of this section in full otherwise we will not be able to process your information

Disclosure of Information
I/We agree that Stafford and Rural Homes will keep our personal information for use in the performance of any of its services, and agree that disclosure of relevant personal information can be made to other organisations working with Stafford and Rural Homes to deliver services or provide housing.

  • I/We understand that by giving a false statement and withholding information it is an offence (Section 171 of the Housing Act 1996) and if found guilty of this offence I/We may be liable for a fine of up to £5,000.
  • I/We confirm that the information given in this application form is correct to the best of my/our knowledge.
  • I/We agree to notify SARH of any changes in the details given in this form.
  • I understand that action can, and may be taken against me/us if I/we fail to provide up to date information regarding my/our circumstances.

By submitting this applicant you are agree that my personal information can be displayed on Stafford & Rural Homes Website and at its reception areas in order to improve my chances of finding a mutual exchange.

By submitting this form you certify that the information given on this form is correct, and you understand that, should it prove that a false statement has been made action may be taken against you.

Please ensure that you have provided proof, where required. All proofs must be dated within the last 4 weeks.
   
Is there any further information you feel that we should be providing? Yes No
If yes please supply details
Are you satisfied with the way we are dealing with your application?  
If no please supply details
   

Information to Applicants

Applicants are able to:

  1. View information contained on our computer system
  2. Change information regarding areas of choice and circumstances
  3. Seek advice, guidance and information on re-housing options
   
Do you feel you will need help to 'bid' for properties we advertise? Yes No
YOU NEED TO ANSWER YES OR NO TO THIS QUESTION
Please provide the name of the person who you would like to act on your behalf.
By completing this, you are giving us permission to discuss any aspect of your application with this person