Mutual Exchange Application form Purpose of this form Once you have identified a possible Mutual Exchange partner, you must tell SARH by completing this form. SARH will then assess your application and inform you whether the Exchange can go ahead. All parties MUST have written consent from their landlord before an Exchange can happen. This form should be completed by the party whose landlord is Stafford and Rural Homes. More information about Mutual Exchange.Your detailsName* MrMrsMissMsDrProf.Rev. Your title Your first name Your surname Your date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920National Insurance Number*Your address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Your phone number*Your email address Is your tenancy a Joint TenancyYesNoIf yes, provide the joint tenant's info belowJoin tenants detailsJoint tenant name* MrMrsMissMsDrProf.Rev. Joint tenants title Joint tenants first name Joint tenants surname Joint tenant date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Joint tenant phone number*Joint tenant email address National Insurance NumberMedical NeedsDo you or anyone in your household have medical needs?*YesNoIf yes, please provide details belowMedical needs InformationDetails of medical needsHas your property been adapted?YesNoIf yes, please provide details below.Details of adaptionsWould you or anyone in the property benefit from any of the following adaptations?Please tick as appropriate Wet room/level access shower Ground floor accommodation/access Stair lift People living at your propertyApart from those listed above, does anyone else live at your current property?*YesNoDetails of those living at your current propertyPlease list anyone else living at your current property. For each person, you must provide: - Full name - Date of birth - National Insurance number (if applicable) - Relationship to main tenantDo you have any pets?*YesNoDetails of petsAre you in receipt of Housing BenefitYesNoWhy do you wish to exchange your property?* Want to move area for family reasons Want to move area for work reasons Want to move to a larger property Want to move to a smaller property Can't afford to live here any more/Bedroom Tax Would just like a change Other Are you or anyone on your application related to any Board member or staff member of Stafford and Rural Homes?Or are you, or anyone on your application, related to anyone who has been a Board Member or member of staff of Stafford and Rural Homes in the last 12 months? Yes DetailsPlease provide further detailsThe tenant you wish to Exchange withTenant Name* Title MrMrsMissMsDrProf.Rev. First name Surname Tenant telephone*Address of the property you wish to move to* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is this tenancy a Joint tenancy?*YesNoJoint tenant detailsJoint tenant name Title MrMrsMissMsDrProf.Rev. First name Surname TelephoneMedical needsDoes anyone in this household have medical needs?*YesNoIf yes, please provide details belowDetails of medical needsHas the property been adapted?YesNoIf yes, please provide details belowDetails of adaptionsThe property you wish to move toWho is the Landlord of the property you wish to move to?Stafford and Rural Homes (SARH)Property type*HouseApartment/flatBungalowMaisonetteBedsitProperty floor*GroundFirstSecondNumber of bedrooms*12345+Are there any pets in the household?*YesNoDetails of petsMutual Exchange GuidanceImportant information*• It is your responsibility to ensure that your property is clear of rubbish prior to the exchange taking place; SARH will not accept responsibility for any rubbish found internally or externally. By checking 'Agree', I understand that: • Giving a false statement and withholding information is an offence and if found guilty of this offence (Section 171 of the Housing Act 1996) I may be liable for a fine of up to £5000. I believe that all of the information given is true and correct. • Stafford and Rural Homes will keep this 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. • If I owe any money to SARH for any type of tenancy arrears or rechargeable repairs, I will need to clear those arrears in full within 48 hours of an offer being made, or prior to approval being granted for a Mutual Exchange. • If SARH identify any areas of concern that are in breach of my tenancy conditions, my application to Exchange will be suspended. Agree Data Protection Notice* I confirm I have read and understood the SARH Privacy Policy CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
