Winsleys Charity

Application Form 22 Winsley Square

Winsleys Charity (Registered Charity No. 206000) Colchester CO1 2AU
01206 794064

The following information will be used in assessing your application. It will be kept
confidential to those within the Charity responsible for considering your application.

Applicants will normally be 65 years of age or over. In the case of joint applications
at least one applicant must be aged 65 years or over.

Applicants are advised that failure to disclose any relevant information may
prejudice their application. Misleading or inaccurate information may lead to your
appointment being set aside at some time in the future and your having to leave the
almshouse.

PART 1: Personal information

A: Primary applicant

Name _______________________________________ Address __________________________

___________________________________________________ Postcode ___________________

Previous address [if less than 5 years at current address]

________________________________________________________________________________

____________________________________________________ Postcode __________________

Telephone No. ____________________________ Mobile No. ___________________________

Date of Birth ____/_____/______ Age ______ Place of Birth __________________________

Years lived in Colchester __________ Other connections with Colchester:

_________________________________________________________________________________

_________________________________________________________________________________________________

Occupation ______________________________ Current Past Hours a week ______

Employer _______________________________________________________________________

B: Secondary Applicant

Relationship to Primary Applicant:

Partner Son/Daughter Other Please specify _____________________________

Name _______________________________________ Address __________________________

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 Winsleys Charity
Application Form 22 Winsley Square
Winsleys Charity (Registered Charity No. 206000) Colchester CO1 2AU
01206 794064

___________________________________________________ Postcode ___________________

Previous address [if less than 5 years at current address]

________________________________________________________________________________

___________________________________________________ Postcode __________________

Telephone No. ____________________________ Mobile No. ___________________________

Date of Birth ____/_____/______ Age ______ Place of Birth __________________________

Years lived in Colchester __________ Other connections with Colchester:

_________________________________________________________________________________

_________________________________________________________________________________________________

Occupation ______________________________ Current Past Hours a week ______

Employer _______________________________________________________________________

PART 2: Current housing

A: Whom you live with now

Who lives with you at your current address other than the secondary
applicant? (i.e. people who will NOT be moving with you to Winsleys)
_________________________________________________________________________________________________

_________________________________________________________________________________

Where will they live if you move to Winsleys? _____________________________________

_________________________________________________________________________________________________

(Note: Properties at Winsleys are suitable for single or couple occupation.)

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 Winsleys Charity
Application Form 22 Winsley Square
Winsleys Charity (Registered Charity No. 206000) Colchester CO1 2AU
01206 794064

B: Type of property you live in now

Flat Maisonette House Bungalow Hostel Other

If other, please specify __________________________________________________________

If you don’t live on the ground-floor, which floor do you live on? ____________________
Do you share any of these facilities with another household (i.e. people other than
the second applicant) Bath/shower Kitchen Lounge

C: Type of resident currently

Do you own your current home? Yes Go to Section D

Are you a tenant? Yes Go to Section E

Are you a lodger? Yes Go to Section E & F

Have you ever owned a property? Yes Go to Section G

D: Owning your Home

What is the current estimate of the value of your property? £______________________

Do you own the property outright or is there an outstanding mortgage?

Owned outright Mortgage Mortgage capital outstanding £________________

Years remaining on mortgage _____________ Any arrears? How much? _________

If in arrears, has Court action been taken against you? (please attach evidence)

Freehold Leasehold Lease remaining in years ___________

What are your intentions regarding this property if you are offered an Almshouse?

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

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 Winsleys Charity
Application Form 22 Winsley Square
Winsleys Charity (Registered Charity No. 206000) Colchester CO1 2AU
01206 794064

E: Type of Tenancy
Council Housing Association Private Landlord Tied accommodation
Name and address of your landlord ______________________________________________
_________________________________________________________________________________
________________________ Postcode ______________ Phone _________________________
Your rent? £ ____________ weekly / monthly Arrears? How much? £ _____________
If in arrears, has Court action been taken against you? (please attach evidence)
Have you been given notice to end your tenancy? (please attach evidence)

F: Living as a lodger
Please give details of the people you lodge with and their relationship to you. Please
exclude details of any person who is a second applicant.
Name _____________________________________ Age ______________ Male Female
Relationship to you (e.g. brother, sister, friend) ____________________________________
Do you share a bedroom with this person? Yes No

G: Previous properties owned by you

Last property owned by you:
Address ________________________________________________________________________
_________________________________________________________________________________
________________________________________________________ Postcode _______________
Reason for sale of property ______________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________ Date sold ______________
Price sold for £ ________________ Equity released (if any) £ _______________________

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 Winsleys Charity
Application Form 22 Winsley Square
Winsleys Charity (Registered Charity No. 206000) Colchester CO1 2AU
01206 794064

PART 3: Reasons for application

In order for us to best understand your needs please tell us why you wish to move:

Tied accommodation Retiring from Army Retiring from Clergy Other

If other, please give details (continue on separate sheet if necessary)

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Please give any other information you feel is relevant such as relationship break-
down, harassment etc. Please attach evidence, such as letters, police reports etc)

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

If you need to leave your current residence (due to lease expiring, tied
accommodation no longer available etc), please tell us the date by which you need
to move ______/_______/________ (please attach evidence)

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 Winsleys Charity
Application Form 22 Winsley Square
Winsleys Charity (Registered Charity No. 206000) Colchester CO1 2AU
01206 794064

PART 4: Finances (Please answer all questions. Enter ‘NIL’ where appropriate.)

NET INCOME Weekly (Yours) Weekly (second

applicant)

PENSIONS State Pension

Widow’s Pension/Widow’s
Allowance

War Disablement Pension

War Widow’s Pension

Superannuation

(pension from former employer)

Widow’s Pension from Late Hus-

band’s

Employment

Pension Credit

ALLOWANCES Attendance Allowance

Mobility Allowance

Invalid Care Allowance

Severe Disablement Allowance

Disability Living Allowance

BENEFITS Incapacity Benefit

Income Support

Housing Benefit

Council Tax Benefit

OTHER Maintenance Received by Yourself

Voluntary or Charitable payments

received

Rental Income from any property

Any Other Income – give details

TOTALS

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 Winsleys Charity
Application Form 22 Winsley Square
Winsleys Charity (Registered Charity No. 206000) Colchester CO1 2AU
01206 794064

Savings & Investments: (Please answer all questions. Enter ‘NIL’ where appropriate.)

YOU SECOND APPLICANT

Bank Accounts

Post Office Accounts

Building Society Accounts

National Savings Certificate (state date

bought)

ISAs or similar savings

Premium Bonds

Redundancy Payment (if in last twelve

months)

Cash – this includes any cash held at home

Any Other Capital – give details

Stocks/shares/unit trusts
Please give current value (or state name of
companies and number of stocks/shares
held on a separate sheet of paper)

If you, or your partner, own property other than the one you live in, please give
details below

Address ______________________________________________________________________
_______________________________________________________________________________
_________________________________________________________ Postcode ____________
Date Purchased _______________ Current Value £ ____________________
Mortgage Capital remaining £ ________________ Years remaining _________________
Do you or your partner own any companies or businesses? Yes No

If so, please give details on a separate sheet of paper

Is your financial situation likely to change in the near future? Yes No

If so, please give details _________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

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 Winsleys Charity
Application Form 22 Winsley Square
Winsleys Charity (Registered Charity No. 206000) Colchester CO1 2AU
01206 794064

PART 5: Health information

Primary Applicant:

Are you able to manage stairs without difficulty? Yes No

Do you have a disability? Yes No

If so, please give details: ___________________________________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________

Do you have carers providing any support on a regular basis? Yes No

If so, please give details: ___________________________________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________

Do you need to use a wheelchair indoors? Yes No

Do you need to use a wheelchair outdoors? Yes No

Do you need to use a walking stick or frame? Yes No

Do you you have to climb stairs to use the bathroom/toilet? Yes No

Secondary Applicant:

Are you able to manage stairs without difficulty? Yes No

Do you have a disability? Yes No

If so, please give details: ___________________________________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________

Do you have carers providing any support on a regular basis? Yes No

If so, please give details: ___________________________________________________________________

_________________________________________________________________________________________________

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 Winsleys Charity
Application Form 22 Winsley Square
Winsleys Charity (Registered Charity No. 206000) Colchester CO1 2AU
01206 794064

_________________________________________________________________________________________________

Do you need to use a wheelchair indoors? Yes No

Do you need to use a wheelchair outdoors? Yes No

Do you need to use a walking stick or frame? Yes No

Do you you have to climb stairs to use the bathroom/toilet? Yes No

Are there any other health factors or specific medical reasons that you would wish
the Trustees to take into consideration when assessing your application?

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Please confirm that the Trustees may consult your GP(s) (in confidence) in
connection with your application. YES/NO

GP details (primary applicant) ___________________________________________________

_________________________________________________________________________________________________

GP details (primary applicant) ______________________________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________

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 Winsleys Charity
Application Form 22 Winsley Square
Winsleys Charity (Registered Charity No. 206000) Colchester CO1 2AU
01206 794064

PART 6: Certification

Our governing instrument states that residents should be of good character and so
we need to ask if you have any criminal convictions. A conviction will not
automatically exclude you from being considered as an applicant but Trustees need
to be fully aware of your circumstances. Do you have any criminal convictions?

YES NO

I certify that the details above are correct to the best of my knowledge and belief
and that this application is submitted in good faith. I confirm that I am able to look
after myself, with the assistance of family and social services if necessary. I accept
that if I am appointed as a resident I shall not be a tenant. Any weekly sum I pay will
be a maintenance contribution and not a rent.

Signed (Primary applicant) _____________________________________________________.

(PRINT NAME IN CAPITAL LETTERS) ___________________________________________

Date _______________________

Signed (Secondary applicant) __________________________________________________

(PRINT NAME IN CAPITAL LETTERS) ___________________________________________

Date _______________________

Data Protection Statement: it is part of the Trustees’ responsibilities to ensure that

applicants for almshouses are suitably qualified under the terms of the charity’s
governing instrument. Trustees, therefore, need to investigate the personal
circumstances of applicants. The personal data supplied on this form, and other
information relating to an almshouse appointment or your care management, will be
held on file. Some details may be checked with relevant organisations but none will
be disclosed for any inappropriate purpose. You may have access to your personal
information on request.

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 Winsleys Charity
Application Form 22 Winsley Square
Winsleys Charity (Registered Charity No. 206000) Colchester CO1 2AU
01206 794064

PART 7: References

Please give details of anyone who has known you for at least the past five years and
knows your present circumstances. This can include your GP, Social Worker,
Minister, neighbour or friend but should not include any person related to you.
Please do not ask your MP to act as a referee as it will be unlikely that they know you
as well as someone else. We may contact your referees before deciding on your
application but only if you are short-listed.

Reference 1:

Name ___________________________________________________________________________

Address ________________________________________________________________________

___________________________________________________________ Postcode ____________

Telephone _______________________________ Relationship __________________________

Reference 2:

Name ___________________________________________________________________________

Address ________________________________________________________________________

___________________________________________________________ Postcode ____________

Telephone _______________________________ Relationship __________________________

Reference 3:

Name ___________________________________________________________________________

Address ________________________________________________________________________

___________________________________________________________ Postcode ____________

Telephone _______________________________ Relationship __________________________

Once you have completed the form please return it to the Charity’s office at the
address above. Once we receive your application we will acknowledge receipt. If
we need further information we will contact you. Normally, we will confirm whether
you have been short-listed or not within 28 days. If a vacancy becomes available we
aim to prioritise those most in need so it is important you fill out as much of the form
as possible. If we are able to offer you a property we will be in touch.

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