Number

Name

APPLICATION
FOR HOUSING
Please answer ALL the questions on the form, they are all relevant to determining your application. For every
applicant, include at least two forms of proof of identity and proof of current address.
Failure to answer all the questions and providing the necessary proofs could lead to a delay in us dealing
with your application.
Forms of identification include
Full birth certificate
Medical card
Marriage certificate
Driving licence
Passport
Proof of Benefit entitlement Tenancy
Agreement

Proof of current address include

Recent Bank Statement
Council Tax Bill
TV Licence
Recent Utility Bill (eg. Gas / Electricity /Telephone
but not Mobile phone)

For every child included on the application form we will need proof of child tax credit.
We must see the original documents, photocopies will not be acceptable.
When completed please return this form to:

Housing Services
Sherwood Lodge
Bolsover
Derbyshire
S44 6NF

Tel:
01246 242424
Email:
enquiries@bolsover.gov.uk
Website: www.bolsover.gov.uk

or any of our Contact Centres, please see address on Page 19.

Providing Access for All - Please see statement on Page 26

Page 1

SECTION A

YOU AND YOUR HOUSEHOLD

APPLICANT

JOINT APPLICANT

Present address:

Present address:

Post Code:

Post Code:

Correspondence address (if different from above)

Correspondence address (if different from above)

Post Code:

Post Code:
Length of time at current address :

Length of time at current address :

Mr
Mr

Mrs

Miss

Ms

Mrs

Miss

Ms

Other - please state

Other - please state

First Name(s):

First Name(s):
Surname:
Surname:

National
Insurance No. :

National
Insurance No. :

Date of Birth:

Date of Birth:

Single

Married

Separated

Divorced

Widowed

Living
together

Single

Married

Separated

Divorced

Widowed

Living
together

Relationship to applicant one eg. spouse, child,

partner etc. :

Home Tel. No. :

Home Tel. No. :

Work Tel. No. :

Work Tel. No. :

Mobile Tel. No. :

Mobile Tel. No. :

EMail Address :

EMail Address :

Village / Town
of Origin:

Village / Town
of Origin:
Page 2

Have you, your partner / joint applicant ever been known by another name?
Yes

No

If yes, please give details:

Please list everyone wishing to be rehoused with you (including children)

Full name

Sex
(M/F)

Date of
birth

Age

Relationship to
applicant

Currently living with

applicant (tick)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No

If anyone included in the application lives at a different address, please enter their details below:
Full name

Address

Reason for living apart

Please give details of anyone who shares your accommodation at present but is not to be rehoused with
you:
Surname

First name

Relationship

Date of birth

If you have access to children, please give these details and provide proof of access for example, joint
residency order, letter from solicitor, letter from ex-partner:
Childs name

Age

Date of birth

Page 3

Number of days
access each week

Is anyone wishing to be rehoused expecting a baby?

Name of Person

Yes

No

Date when baby is due

PLEASE ATTACH A COPY OF YOUR CERTIFICATE CONFIRMING PREGNANCY. ALSO PROVIDE A COPY OF
BIRTH CERTIFICATE WHEN CHILD BORN

EMPLOYMENT AND INCOME

APPLICANT

JOINT APPLICANT

Occupation :

Occupation :

Employer :

Employer :

Address:

Address:

Post Code:

Post Code:

Working full time

Working full time

Working part time

Working part time

Government training / New Deal

Government training / New Deal

Job Seeker

Job Seeker

Retired

Retired

Full time student

Full time student

Unable to work

Unable to work

Carer

Carer

Number of
hours worked :

Number of
hours worked:

Do you currently claim any benefits?

Yes

No

If yes, what benefits do you claim?

Please list all below:

Continued overleaf ......

Page 4

Do you have any close relatives living in the Bolsover District Council area?
If yes please specify
Name

Address

Yes

Relationship

Page 5

No

SECTION B

WHERE YOU LIVE NOW

Please list all of your previous addresses during the last 10 years. Please start with your present address:

APPLICANT
Address

Please indicate if
Council or Housing
Association, Private
Tenant, Owner
Occupier or Other

Dates From / To

Reason for Leaving

JOINT APPLICANT

Do you have any of the following in your present accommodation? (please tick):

None

Sole Use

A bedroom
A bathroom
Inside toilet
Outside toilet
Hot water
Mains cold water
Kitchen (including cooking facilities)
Living room
Steps at front
Steps at rear
Means of heating

Page 6

Shared

Is shared with whom

INFORMATION ABOUT YOUR HOME

APPLICANT

JOINT APPLICANT

Are you : (please tick only one)

Are you : (please tick only one)

A council tenant

In hospital

A council tenant

In hospital

A housing
association tenant

In housing for
older people

A housing
association tenant

In housing for
older people

An owner occupier
An owner occupier
(low cost home
ownership)
A private tenant
In tied housing
In supported
housing
In a probation
hostel
In a residential
care home

In prison

An owner occupier

In any other
temporary
accommodation

An owner occupier
(low cost home
ownership)

In a foyer

A private tenant

In short life
housing

In tied housing

In a mobile home/
caravan

In supported
housing

In a refuge

In a probation
hostel

In a direct access
hostel

In prison
In any other
temporary
accommodation
In a foyer
In short life
housing
In a mobile home/
caravan
In a refuge
In a direct access
hostel

In bed & breakfast

In a residential
care home

In bed & breakfast

Living with family

Rough sleeping

Living with family

Rough sleeping

Living with friends

Childrens home/
foster care

Living with friends

Childrens home/
foster care

Home office
asylum support

Home office
asylum support

Other

Other

If applicable, please give details of expected discharge date or release date and any arrangements made
thereafter

If private rented tenant or housing association tenant please give name and address of landlord and a
copy of your tenancy agreement

Page 7

What type of property do you live in? (tick one box) :

House

Bungalow

Sheltered housing

Flat

Ground Floor
First Floor

Hostel

Boat

Bedsit

Ground Floor
First Floor

Caravan

Mobile home

Maisonette

Ground Floor
First Floor

B&B

Sleeping rough

Other (please give details):

How many bedrooms does your current property have?

Does your property suffer from any disrepair which in your view affects your quality of life?
Yes

No

If yes please give details:

Why do you want to move? (you can tick more than one box)
You are overcrowded

Your property is too large for your family

Property unsuitable for medical reasons

Property is in poor condition

Affordability - mortgage / rent too high

To move nearer to family/friends/school

To move nearer work

To move to accommodation with support

To move to independent accommodation

Loss of tied accommodation

Assured shorthold tenancy has ended

Eviction or repossession

Domestic violence

Relationship breakdown with partner (non violent)

Asked to leave by family or friends

Harassment - racial/disability/gender/transgender/sexual orientation

Problems with neighbours

Left home country as refugee

Discharged from prison / long stay hospital

Decanted by Bolsover District Council to another

property

Other (please give details in box overleaf )

Page 8

Other Properties
Do you or your partner own or have a financial interest in any property that you are not living in?
Yes

No

If yes please give details:

Do you have any pets?

Yes

No

If yes please tell us what type and how many:

Page 9

SECTION C

HEALTH & SOCIAL FACTORS

Medical Factors
Social problems such as difficulties with neighbours or the dislike of the locality cannot be considered to be
medical problems. Please give brief details of any relevant health problems that affect you or any member
of your household. A further questionnaire will be issued to ascertain your medical priority:

Do you consider yourself or any member of your household to be disabled?

Yes
No
(For a definition of Disabled please see page 15)
Please describe how these medical problems are affected by your present home, eg unable to get
upstairs, difficulty using bathroom etc.

Has your present home been provided with adaptations, eg ramp, shower etc?
If yes please give details:

Page 10

Yes

No

Do you need to move to give / receive support for health reasons?

Yes

No

If yes please give details, including name and address of people concerned:

Do you have a GP, social worker, health or other advocate who can add support to your housing application
if requested:
Yes

No

If yes please give details :

Do you have a ....?

Name

Contact Address

Social Worker

Probation Officer

Health Visitor

Community Psychiatric Nurse

Connexion Personal Advisor

Is anyone helping you to be

rehoused

Page 11

Tel. Number

SOCIAL NEEDS FACTORS

Points may be awarded to applicants who may come to harm or whose welfare is at risk in their current
accommodation. Please tell us if you or anyone included in your application would qualify for these points
and why. We will need you to substantiate all claims before points are awarded.

Page 12

SECTION D

GENERAL INFORMATION

Failure to complete both pages 13 and 14 completely could result in your application for rehousing
not being considered.
Have you previously been evicted from a property owned by a local authority, housing association or
private landlord?
Yes

No

If yes please give details of address and reason:

Has a landlord ever started action against you or your household for anti social behaviour?
Yes

No

If yes please give details:

IMMIGRATION STATUS
Have you resided in the United Kingdom for the past 5 years?
Yes

No

If no please give details:

CONVICTIONS
Have you or any other person normally residing with you or who will be residing with you, ever been
convicted or have any prosecutions pending for any criminal offence?
Yes

No

If yes please give details:

Page 13

NATIONALITY
APPLICANT

JOINT APPLICANT
How would you describe your sexuality?

How would you describe your sexuality?

Heterosexual

Gay

Lesbian

Bisexual

Prefer not to say

Heterosexual

Gay

Lesbian

Bisexual

Prefer not to say

Have you lived in another country in the last five

years?

Have you lived in another country in the last five

years?

Yes

Yes

No

No

Austria

Latvia

Austria

Latvia

Belgium

Lithuania

Belgium

Lithuania

Cyprus

Luxembourg

Cyprus

Luxembourg

Czech Republic

Malta

Czech Republic

Malta

Denmark

Netherlands

Denmark

Netherlands

Estonia

Poland

Estonia

Poland

Finland

Portugal

Finland

Portugal

France

Slovakia

France

Slovakia

Germany

Slovenia

Germany

Slovenia

Greece

Spain

Greece

Spain

Hungary

Sweden

Hungary

Sweden

Ireland

Other - Where?

Ireland

Other - Where?

Italy

Italy
When did you come to live in this country?

D D

M M

When did you come to live in this country?

D D

/ YYYY

What is your nationality?

M M

/ YYYY

What is your nationality?

Page 14

EQUAL OPPORTUNITIES MONITORING FORM

This section is not relevant in determining your application, however completion of the relevant
details will help us to ensure we are providing a fair service.
APPLICANT
JOINT APPLICANT
Please tick the appropriate box to indicate your
cultural background :

Please tick the appropriate box to indicate your

cultural background :

A. White

A. White

C. Asian or Asian British

C. Asian or Asian British

British

Indian

British

Indian

Irish

Pakistani

Irish

Pakistani

Polish

Bangladeshi

Polish

Bangladeshi

Italian

Other

Italian

Other

Other
B. Mixed

Other
D. Black or Black British

B. Mixed

D. Black or Black British

British

Caribbean

British

Caribbean

White & Black

Caribbean

African
Other

White & Black

Caribbean

African
Other

White & Black

African

White & Black

African

E. Other Ethnic Group

E. Other Ethnic Group

White & Asian

Chinese

White & Asian

Chinese

Other

Gypsy

Other

Gypsy

Dual heritage

Dual heritage

Other

Other

Please tick the appropriate box to indicate your

religion or beliefs:

Please tick the appropriate box to indicate your

religion or beliefs:

None

Buddhist

Christian

None

Buddhist

Christian

Hindu

Jewish

Muslim

Hindu

Jewish

Muslim

Sikh

Other

Prefer not
to say

Sikh

Other

Prefer not
to say

Disability
The definition of Disability in the Disability Discrimination Act 1995 is A physical or mental impairment
which has substantial and long term adverse effect on a persons ability to carry out normal day to day
activities.
Do you consider yourself to be disabled?
Yes
No

Do you consider yourself to be disabled?

Yes
No

If yes, what are your impairments? Please tick all

that apply.

If yes, what are your impairments? Please tick all

that apply.

Mobility

Visual

Mobility

Visual

Speech

Hearing

Speech

Hearing

Wheelchair user

Learning Disability

Wheelchair user

Learning Disability

Mental Health
condition inc.
Depression

Long Standing
Health Condition
eg. Cancer, HIV

Mental Health
condition inc.
Depression

Long Standing
Health Condition
eg. Cancer, HIV

Other - Please State

Other - Please State

Page 15

OTHER HOUSING OPTIONS

Mutual Exchange
Council and Housing Association tenants may exchange properties providing they have written permission
from their landlords. The mutual exchange list is a way of finding someone to exchange with. If you apply,
the details about your property will be displayed on the mutual exchange list on the Internet and in
designated locations.
If you are interested please tick in the box provided

Shared Ownership
Shared ownership requires the applicant to buy a share of the price of a particular Housing Association
property (normally half ) and rent the remaining share from the Housing Association. The owned share can
be gradually increased until the whole property is bought.
If you are interested please tick in the box provided

Do you want to be considered for nomination to a Housing Association?

Yes

No

Do you want to be considered for nomination to a private landlord?

Yes

No

If you have answered yes to the above, we will need to share your information with other housing providers.
Please tell us if you dont want us and where it with a specific organisation. Please refer to mean data
protection statement on page 17.

Page 16

DECLARATION
Do you wish to give authorisation for someone to act on your behalf, for example, social worker, support
agency worker, family member. Please give name and contact details.

FOR THE ATTENTION OF ALL APPLICANTS

IMPORTANT NOTICE - HOUSING ACT 1996 - s.171 & s.214 - FALSE STATEMENTS
Where a person approaches the Housing Department seeking an allocation of housing or claiming to be
homeless or threatened with homelessness, the above Act makes it an offence, punishable with a fine,
for a person to make a false statement or to withhold information which is relevant to their claim. For
homeless applicants it is also an offence to fail to inform the housing authority of any material changes in
circumstances which may occur between the initial interview and such time as notification of the Councils
decision is received.
NATIONAL FRAUD INITIATIVE
NOTIFICATION TO DATA SUBJECTS (HOUSING RENTS)
The authority is under a duty to protect the public funds it administers, and to this end may use the
information you have provided on this form for the prevention and detection of fraud. It may also
share this information with other bodies responsible for auditing or administering public funds for
these purposes. For further information see www.bolsover.gov.uk/national-fraud-initiative.html or
contact Mr John Brooks CPFA, Director of Resources 01246 242431.
FOR THE ATTENTION OF ALL APPLICANTS
DECLARATION
The information I provide is accurate. I understand that if I obtain accommodation by providing inaccurate
information, the Council may take legal action to recover the property.

Signature of applicant

Date

Signature of joint applicant

Date

I am an officer or member of Bolsover District Council or have been within the last 10 years.
I am a close relative / close friend of an officer or member of Bolsover District Council. Please give
name of officer/member
None of the above apply to me
If you are a relative / close friend of an officer or member, please state their name and the nature of your
relationship. (eg. son, daughter etc.)
Name

Relationship

All personal information provided to Bolsover District Council will be held and treated in
confidence in accordance with the Data Protection Act 1998. It will only be used for the purpose for
which it was given and may be shared with other council departments or third party organisations.
Page 17

WHAT ACCOMMODATION DO YOU NEED?

The type and size of accommodation that you may be offered will depend on the size of your family. Please
refer to the Bolsover District Council - Choice Based Letting Information Booklet for details of what you may
be eligible for.
Would you accept any type of property as long as it is suitable for your needs?
Yes

No

If NO, please tick the type(s) of property you would accept. Please note: If you are in a priority group you may
be offered any type of property suitable for your needs.
House

Bungalow

Sheltered Flat

Sheltered Bedsit

Ground Floor Flat

Housing with support

First Floor Flat

How many bedrooms do you want?

You cannot ask for a property larger than your family needs.
You can ask for a smaller property (for example, one bedroom less) with some exceptions.
See the Choice Based Letting Information Booklet for further details.

Page 18

CONTACT CENTRE AREAS WITH VILLAGES

Clowne Contact Centre Area

9 Church Street, Clowne, Derbyshire

Villages
Barlborough
Clowne
Creswell
Hodthorpe
Whitwell

Shirebrook Contact
Centre Area
2a Main Street,
Shirebrook, Notts

Villages
Langwith
Langwith Junction
Shirebrook
Whaley Common
Bolsover Contact
Centre Area
Sherwood Lodge,
Bolsover

Villages
Bolsover
Bramley Vale
Doe Lea
Glapwell
Hillstown
New Houghton
Palterton
Shuttlewood
Scarcliffe
Stanfree

OPENING TIMES
Office Opening Times
9.00am -5.00pm
Monday - Friday
9.00am - 12.30pm
Saturday

South Normanton
Contact Centre Area
124a Martket Street,
South Normanton, Derbyshire

Villages
Blackwell
Hilcote
Newton
Pinxton
South Normanton
Tibshelf
Westhouses

Telephone Lines
8.00am -5.00pm
9.00am - 12.30pm

Page 19

Monday - Friday
Saturday

Please tick the box next to the town/villages where you would accept an offer of housing.
Please note however that some villages have limited availability.
Barlborough

New houghton

Blackwell

Newton

Bolsover

Palterton

Bramley vale

Pinxton

Clowne

Scarcliffe

Creswell

Shirebrook

Shuttlewood

Doe lea

Stanfree

Glapwell

South normanton

Hilcote

Tibshelf

Hillstown

Westhouses

Hodthorpe

Whitwell
Langwith

Langwith junction

Please rank from the above town/villages your top three preferred areas:
First:
Second:
Third:
Page 20

ADDITIONAL INFORMATION
Please use this space to provide any other information which you feel may be relevant to your
application.

Page 21

OFFICE USE ONLY

Date

Information

Initials

Identification verified

Eligibility

Check for written off arrears

Rent - current FTA

Sundry Debts / recharges

Registration card issued

Page 22

AREA AND PROPERTY TYPE PREFERENCE

This section is not mandatory and is not relevant to determining your application for housing.
This information below is about where you would like to live and in what type of property. It is
not current property availability but will help our Strategy Team when considering what types of
accommodation we will need in our district in the future.
Please tick the area you would like to live in:
Clowne Contact Centre Area
Barlborough

Shirebrook Contact Centre Area

Upper Langwith
Langwith

Renishaw

Clowne

Spinkhill

Langwith Junction

Whaley

Creswell

Steetley

Pleasley

Whaley Thorns

Elmton

Whitwell

Shirebrook

Hodthorpe

Whitwell Common

Mastin Moor
Bolsover Contact Centre Area
Astwith

South Normanton Contact Centre Area

New Houghton

Blackwell

South Normaton

Carr Vale

Palterton

Broadmeadows

Stainsby

Bolsover

Scarcliffe

Hardstoft

Tibshelf

Bramley Vale

Shuttlewood

Newton

Westhouses

Doe Lea

Stanfree

Pinxton

Glapwell

Stoney Houghton

Hillstown
Please tick the type of accommodation you would prefer if available:
0 bed
House

n/a

Flat ground floor

n/a

Flat above ground floor

n/a

Bungalow

n/a

Sheltered accommodation

n/a

Bedsit
Social Rented
Shared Ownership

Page 23

1 bed

2 bed

3 bed

4 bed

4+bed

n/a

n/a

n/a

n/a

n/a

Page 24

WHAT TO DO NOW
Please check that you have . . .
Filled in and signed the application form for yourself, a joint applicant and other members of your
household, if applicable.
Included the required proof of identity and proof of address.
Checked the price of posting this form and any other supporting proof, if you are sending it through
the post. Failing to put the correct postal price on your envelope may result in applications not being
received and processed.
When we get your housing application:
We will let you know we have received it within three working days.
We will write to you within five working days of receiving it if we need any further information or proof.
We will contact you within ten working days if we need to arrange an interview at your home or nearest
Contact Centre.
We will contact you within twenty working days to confirm that your application is active or registered
(started to be used)
If we can not start your application within 20 working days, we will write and tell you why. The delay may be
because we need more information from you or another agency.

Confirmation of Application Receipt

I acknowledge receipt of your housing application received.
If we require any further information you will be contacted
within 5 working days. You will receive confirmation within 20
working days that your application is active or registered.
If you have any questions relating to your housing
application.

Page 25

PROVIDING ACCESS FOR ALL

If you need help understanding any of our documents or require a
larger print, audio tape copy or a translator to help you, we can
arrange this for you. Please contact us on the telephone numbers
at the bottom of the page:
POLISH
Jeeli potrzebuje Pan/i pomocy w rozumieniu tych dokumentw
lub chciaby je Pan/i otrzyma wikszym drukiem, na kasecie
audio lub skorzysta w tym celu z pomocy tumacza, jestemy to
Pastwu w stanie zapewni. Prosimy o kontakt pod numerami
telefonw na dole strony.
ITALIAN
Se avete bisogno di aiuto per capire qualsivoglia dei nostri
documenti o se li richiedete a caratteri grandi, o volete
copie registrate, o necessitate di un traduttore per aiutarvi,
noi possiamo organizzare tutto ci. Per favore
contattateci ai numeri di telefono che troverete in fondo a
questa pagina.
CHINESE

URDU

01246 242407 or 01246 242353.

Other Equalities information is available on our web site.
www.bolsover.gov.uk or by e-mail from equalities.officer@bolsover.gov.uk
Minicom:

01246 242450

Fax: 01246 242423

Page 26