East Herts District Council

Housing Application Form

Before completing the application form please read it through
carefully. Make sure you answer all questions fully. In order to help
us process your form please provide all the relevant
documentation requested below.

If you require any help in filling in the application form please do
not hesitate to contact the Housing Options Team on 01279 655
261.

PLEASE PROVIDE PHOTOCOPIES – NOT ORIGINAL
DOCUMENTS. (N.B. We may request original documents at a
later date if necessary.)

Proof of identity – Birth certificates for all British adults and
children included on the housing application; passports and
immigration documents for adults and children of any other
nationality. (Please ensure that every page of the passport that
contains an entry is copied and any immigration stamps can be
read clearly.)

Proof of any Benefits received for you and your children – e.g
Child Benefit, Tax Credits, JSA, Income Support etc.

Proof of income and savings – e.g. copies of bank statements,
savings passbook and last 3 payslips.

Proof of pregnancy – a copy of the scan photograph is required,
plus a document from the hospital maternity records confirming the
expected date of delivery (EDD).

(PLEASE NOTE: YOUR HOUSING APPLICATION WILL NOT
BE PROCESSED UNTIL COPIES OF THE APPROPRIATE
DOCUMENTS HAVE BEEN RECEIVED.)

Office Use Only

Ref No:

Date:

Initials:

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Section A: Applicant Details

Applicant

Partner

Mr/Mrs/Miss/Ms/Other

(Please state)

Surname

Forenames

Date of Birth

National Insurance Number

Current Address

(If different from applicant)

Postcode

Daytime Tel No:

(Incl STD code)

Home Tel No:

(If different)

Mobile Tel No:

Email Address

Please provide details of other persons in your household in addition to those listed above who are to be housed
with you.

Date of

Relationship

Surname

Forenames

Birth

M/F

to Applicant

Please give details if you, or anyone above, are expecting a child.

Name

Expected Date of Birth

(Written proof of pregnancy is required from a GP or midwife)

www.eastherts.gov.uk

HOUSING APPLICATION

The information you provide on this form will be
treated in the strictest confidence and will be
used by Housing staff to determine your eligibility
and need for housing. Please answer all the
questions as fully as possible. Ask if you need
help with completing this form.

The following question must be answered by all applicants.

Are you, or anybody on your application, subject to any immigration controls due
to a status as a ‘person from abroad’ under the 1996 Asylum & Immigration Act?

Yes

No

If you answer Yes to this question, please contact a member of the Housing Options Team before continuing

with this application.

Section B: Present and Past Residences

Please give details of all your addresses for the last 15 years. Start with the most recent. If there are more than four
addresses, then please continue on a separate sheet.

Applicant

From

To

1.

Present Address

2.

3.

4.

Partner

From

To

1.

2.

3.

4.

If you or your partner have lived in East Hertfordshire for less than one year please give details of any employment
you have had in East Hertfordshire.

Name

Please state name of employer, location of work, and dates of employment

If you or your partner have previously applied to East Herts Council for housing, please provide details if possible, and
also the name you applied under, if different.

Applicant

Partner

2

/

/

If you or your partner have ever held a Council or Housing Association tenancy, please provide details below.

Name of

Reason for

Address

Dates

Landlord

Leaving

Applicant

Partner

If you or your partner have ever owned a home, please state the address and when you owned it.

Applicant

Partner

Address

Dates

From

To

From

To

If you and your partner live outside East Herts and are of retirement age, but have a close relative or any other strong
connection with East Hertfordshire, please give details below.

Section C: Your Present Accommodation

Security of Tenure

Are you being asked to leave your present home within the next year?

Yes

No

(Please provide written proof from your landlord and additional details on Page 6 of this form - Further Information)

For each section below, please tick the boxes which best describe your housing

Property Type

Tenancy Type

House

Private Tenant

Bungalow

Owner Occupier

Maisonette

HM Forces

Ground Floor Flat

Hospital

Upstairs Flat

With Parents

Sheltered Scheme

With Friends

Bedsit Lodgings

Mobile Home / Caravan

Housing provided with your job

B&B / Hotel

Housing Association Tenant

Council Hostel

Local Authority Council Tenant

Other

(Please state)

Temporary accommodation provided by the Council
that is not self-contained
Temporary accommodation provided by the Council
that is self-contained

No Fixed Abode

Other

(Please state)

3

/

/

/

/

/

/

4

Your living space

Please count the rooms you use as bedrooms.
Include living rooms if someone sleeps there regularly. Do not count kitchens or bathrooms.

Tick if shared

with people

Is it a

Tick if shared

who are not

State if a

double

with relatives

relatives and

Room bedroom or

or single

not on your

not on your

Count living room Names of people sleeping in this room

sized room?

application

application

1

2

3

4

5

6

7

Facilities

Please tick if you have these facilities.

How many people

in total do you

Tick if you

share these with who

have this

are not included

Facility

facility

on your application?

Kitchen

Bathroom

Toilet

Running hot and cold water

Defects

Does your home have any major defects, such as dampness?

Yes

No

If yes, please describe:

Details of Your Rent or Mortgage

Applicant

Partner

Rent or mortgage per month

£

£

Are you in arrears?

Yes

No

Yes

No

If ‘Yes’, how much do you owe?

£

£

Please provide the name and address of your landlord or mortgage lender, if applicable.

Applicant

Partner

(if different)

Section D: Financial Circumstances

Please provide details of your employment, if appropriate.

Applicant

Partner

Employment Status

Employed

Unemployed

Employed

Unemployed

(Tick all boxes that apply)

Permanent

Temporary

Permanent

Temporary

Full Time

Part-Time

Full Time

Part-Time

Occupation

Name of Employer

Address of Employer

Place of Work

(if different to above)

Gross Annual Income

Please give details below of any State benefits, Pensions or Allowances you or your partner are receiving.

Applicant

Partner

Type of Benefit, Pension
or Allowance

Weekly Amount

If either you or your partner have any savings, then please state the amount

If you feel your income is too low to enable you to obtain accommodation in the private sector and you do not receive
housing benefit, then please ask a member of staff for a financial assessment form, which you should complete and
return together with this form.

£

£

£

£

5

Section E: Special Factors

Please give details below if any member of your household, who is included on this application, has a serious health
problem that is affected by your present home. (Note: You will be asked to provide additional information)

Please give details if any member of your household on this application requires special housing or adaptations
because of a physical disability. If this section is completed you will be asked to provide additional information by
Papworth Housing Advice Service

Does this person use a wheelchair?

Inside the home

Yes

No

Outside the home

Yes

No

Please tick any of the categories below which apply to you or any member of your household

Learning Disability

Mental Illness

Any Other Special Need (Please give details below)

Further Information

Please use the space below for any additional information about why you are applying for housing.

6

Section F: Where Do You Want to Live

The District has been divided into towns and villages to help you choose the areas where you would prefer to be
housed. By selecting as wide an area as possible, you may improve your prospects of an offer of housing.
Our ability to provide an offer is limited both by the availability of housing you require and your areas of choice.

Please indicate which of the five towns and villages you would prefer to be considered for. You may choose as many as
you wish. If you have a particular preference for a village or estate, please show by circling the village or show under
particular preference.

Anywhere in East Hertfordshire

Towns

Hertford Town

Ware Town

Bishop’s Stortford Town

Sawbridgeworth Town

Buntingford Town

Villages

Nr Hertford/Ware

North West

South East

North East

Bayford

Ardeley

Allens Green

Albury

Birch Green

Aston

Eastwick

Anstey

Bramfield

Benington

High Wych

Braughing

Brickendon

Buckland

Hunsdon

Brent Pelham

Great Amwell

Chipping

Little Hadham

Furneux Pelham

Hertford Heath

Cottered

Much Hadham

Great Hormead

High Cross

Dane End

Widford

Hare Street

Letty Green

Datchworth

Little Hormead

Little Berkhamsted

Great Munden

Meesden

Puckeridge

Haultwick

Stocking Pelham

Standon

Sacombe

Stanstead Abbotts

Throcking

Stapleford

Walkern

Tewin

Westmill

Thundridge

Tonwell

Wadesmill

Wareside

Waterford

Watton-at-Stone

Occasionally East Herts Council get offers of accommodation from other local authority areas.
Please tick if you would be interested in living in any of the following areas:

Harlow

Uttlesford

Braintree

Section G: Alternatives to Rented Housing

Low cost home ownership and other rented opportunities for people in employment and/or
providing services for people in East Herts.

Please tick this box if you are interested in low cost home ownership or mid-market rented opportunities

Please tick this box if you are employed as one of the following: firefighter, police, teacher, health service and
social care worker and are providing a service to the residents of East Herts

Please tick this box if you are employed in the public or private sector and are providing a service to the
residents of East Herts

7

Particular Preference

Section H: Declaration

It is an offence for anyone to knowingly give false information, or to withhold information in connection with an
application to the housing register. Anyone committing such an offence can be removed from the housing register
or if rehoused the Council can seek possession of the tenancy. In both cases the Council may prosecute and if
convicted an applicant may be fined.

I declare that to the best of my knowledge and belief the information given in this application is correct in every detail,
and I have no objection to it being verified. I will advise the Council of any changes in circumstances which may affect
my application.

I also give my authorisation for the Council to contact and share information with other agencies or individual persons
in connection with this application to ensure the best possible service is provided.

Signature of Applicant

Date

Signature of Partner

Date

Section I: Ethnic Monitoring

All applications are monitored to ensure we do not discriminate in our allocations process on the basis of an applicant’s
ethnic or racial origin. To enable us to continue monitoring, please complete the section below. Completing this section
will not affect your application. I would describe my ethic origin as: (please (✓) box)
White

Black or

Asian or
Black British Asian British

British

African

Indian

Irish

Caribbean

Pakistani

Any other

Any other

Bangladeshi

White Background

Black Background

Please specify:

Please specify:

Any other
Asian Background
Please specify:

Mixed

Other

White and Black

Ethnic Origin

African

Chinese

White and Black

All Other

Caribbean

Ethnic Origin
Please specify:

White and Asian

Any Other
Mixed Background
Please specify:

Please return this form to the Housing Options Team, Housing and Community Planning,

Wallfields, Pegs Lane, Hertford, Herts SG13 8EQ

Tel: [phone]