If your circumstances change in any way following your SARHomes registration you will need to complete the below form. Change of Circumstances SARHomes Change of Circumstances formName* First Last Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Registration number*Please confirm or update your current contact detailsHome or mobile phoneWork phoneEmail What would you like to do?Changes to application*Please select as appropriate.Remove my applicationChange of address (If you select this, submit this form without answering any further sections. You will then need to complete a new housing application form on SARHomes.)Add an adult (proof required - for additional adult only)Remove a person from the applicationChange name for existing applicant (proof required)Adding a child or baby due (proof required)Aditional InformationPlease enter information ONLY for the person or people to whom the change of circumstances relateTo add another person click the + NameGenderDate of BirthRelationship to youNI Number (if applicable)Enter address (if different) PregnancyIs anyone on the application form pregnant?YesNoNameDue DateContact address (if different)Further InformationAre in hospital or residential care and unable to return to your home due to serious medical condition?Yes (if yes, please provide written proof from your GP, ward sister or care home matron)NoDo you have to leave your home due to a Closing Order?YesNoAre you likely to lose your accommodation in the next 28 days?YesNoIf yes to the above, are you Working with Stafford Borough Councils Housing Options team?YesNoAre you in temporary supported accommodation and been given a move on date?YesNoDo you have to leave home due to a Compulsory Purchase order?Yes (if yes you must provide proof)NoHave you been assessed by Stafford Borough Council as living in Insanitary Accommodation?YesNoAre you applying for welfare priority due to one of the following?Please tick as appropriate. 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 You are a victim of harassment and your personal safety is seriously threatened 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. There is a serious housing need which is threatening your ability to remain living independently in the community. If you are living in a House in 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) Shared living room Your own kitchen (A cooker in a bedsit room does not count as a kitchen.) Shared kitchen Electricity supply to your property (this is not applicable if the supply has been disconnected due to non-payment) Your own W.C. Shared W.C. A water supply, hot and cold water Heating supply to the property (this is not applicable if the supply has been disconnected due to non-payment) If your income has changed, please give details of your weekly income including all income, benefits and pensionsYouYour PartnerHealth and disabilityDo you or anyone included in your application have any medical condition or disability which is made worse by your present housing situation?YesNoDo you or anyone else on the application have a long-term disability that prevents you/them from carrying out normal day to day activities?YesNoDetailsFull name of whoever has the medical condition or disabilityWhat is the nature of the condition or disability?What is the disability? Blindness or sight loss Mobility problems including the use of wheelchair or mobility scooter Deaf or hearing loss Deaf without speech (if you have an advocate, please supply their contact details below) Learning difficulties/Dyslexia Mental health issues Prefer not to answer Advocate contact detailsIncluding name and phone numberDo you need information to be provided in any of the following ways? Audio CD Audio tape Email Large print Other (please indicate below) OtherIn your present accomodation are you able toYes unaidedYes with aids and adaptations or with supportWith difficultyNot ableDoes not applyClimb stairsReach the toiletReach the bathroomReach your bedroomUse the kitchen/cooking facilitiesPersonal Care eg Bathing, dressing, cleaning or laundryManage financial matters eg. Paying billsGo shoppingDo you have any of the following adaptations within your current home?YesNoDoes not applyRamps to the front doorRamps to the back doorGrab rails to bathGrab rails to w.c.Shower unitStair liftLow level kitchen unitsWider doorwaysOther (please state below)Other adaptions (if applicable)SupportDo you or does anyone in your household receive any support?YesNoDoes the medical condition/disability require you/them to have a carer or receive support from others?YesNoSupport detailsWho is providing the support?Is the carer required to stay overnight?YesNoCare detailsOther details that may support your applicationAny other factors you wish to make us aware of when assessing your application. Tick as appropriate 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? Are you, or anyone listed on this application, required to notify the police in accordance with Section 1 of the Sex Offenders Act 1997? Name of police officeIf you wish to add any further information to support your application, please use the space belowUpdate your referencesYou 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 MEMBERSPlease complete the questions below before you submit the formWhat type of property are you looking for? House Bungalow Apartment Studio apartment How many bedrooms do you require? 1 2 3 4 Guide on eligibility The size of accommodation a household will be eligible for will be assessed from the information you submit on your application. • 2 and 3 bedroom houses: preference will be given to households with children under the age of 18. • 4 bedroom houses: preference will be given to households who will fully utilise all the rooms, for example a household with 4 or more children. • Bedroom requirements: if there is a severe shortage of certain property types in the area, priority will be given to households who need all the bedrooms in a property. It is considered that the following require their own bedroom: - A couple (including husband and wife or partners of the same or opposite sex) - Each child over 9 years of age of different sexes. - Lodgers - Sleeping carers For further details on property size and eligibly criteria please refer to the Choice Based Lettings Policy.Are you interested in buying a home on a low-cost Shared Ownership basis?YesNoWays to applyWe are keen to ensure that our services are accessible. To help us monitor the preferred methods of applying for homes, please indicate which method you will likely use to make an application for a home. Online (through Choice Based Lettings) Telephone In person (e.g. at one of our offices) Ways to applyPlease tick the box(es) below if you would use the following methods of making an application for a home, if they were available. Automated telephone application SMS Text messaging If you feel we should be supplying any further information, please describe it belowAre you satisfied with the way we are dealing with your application?No (provide details)Mutual ExchangeSARH have a Mutual Exchange List which is on public display at SARH Head Officen and online for those tenants wishing to find an exchange between other SARH or RSL (housing association tenants) and Council Tenants. Please select as appropriateFirst ChoiceSecond ChoiceThird ChoiceDo you feel you will need help to Apply for properties we advertise?If yes, please provide the name of the person who you would like to act on your behalf below. By completing this, you are giving us permission to discuss any aspect of your application with this person.YesNoDetails of person to help with bid, if applicableInformation to applicantsApplicants 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 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. If you have indicated in the relevant section above that you wish to join the Mutual Exchange list, by submitting this application you agree that your personal contact information can be displayed on SARH Website and at its reception areas in order to improve your 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.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
