JHC Info & Application Form

Section 1 – About You

First Name

Middle name(s)

Surname

Maiden name (if applicable)

Date of Birth

MM slash DD slash YYYY

Age

Your National Insurance Number (NIN)

Mobile Number

Telephone No

Marital status (evidence will be required)

Section 2 – About your Family

Name of next of kin or other person with authority willing to act for you who may be contacted in an emergency.

MR/MRS/MS/MISS

Name

Address

Post-code

Telephone no

Mobile no

Relationship to you

MR/MRS/MS/MISS

Name

Address

Post-code

Telephone no

Mobile no

Relationship to you

Section 3 – About your present/previous accommodation(s)

Current Address

Post Code

Length of time at this address

Type of accommodation (e.g., 3-bedroom house, 2-room flat, shared)

Do you, or your spouse, own it?

Yes

If ‘yes’, what is its present estimated value?

Is there a mortgage outstanding on the property and, if so, how much is outstanding? If there is no mortgage, please write NONE

If you, or your spouse, have ever owned the property where you currently live, in what circumstances did you cease to be the owner?

If you own property or have ever owned a property other than the one in which you live now, please give details below. This should include property owned abroad as well as in the UK:

Post Code

If you do not own the property where you currently live, who does own this property?

Is this person related to you in any way? If YES what is the relationship?

If rented, please give name and address of landlord:

Do you share this property or the facilities with anyone else if so please state relationship and what accommodation is exclusively for your use?

Current rent £

Rent

per week

month

Do you have security of tenure?

YES

Please tick which of the following is included in the rent?

Gas

Electricity

Heating

Water

Council Tax

Other (Please state)

Do you receive Housing Benefit or other Benefits to help with housing costs?

Yes

Do you receive Council Tax Benefit?

Yes

Why do you wish to leave your present accommodation?

If you are appointed to an almshouse, how much notice are you required to give to your landlord?

Please provide details of all your previous addresses

Post Code

Date

MM slash DD slash YYYY

Reason for moving

Address

Postcode

Date

MM slash DD slash YYYY

Reason for moving

Section 4 – Employment History

You will be required to bring evidence of earnings such as payslips or proof of earnings (if self-employed) to interview.

Are you retired?

Yes

Please give details of your previous/current occupation (if any) including hours of work and brief details of your employment history. (If you are not employed or retired, please state reason and previous work including dates)

Section 5 – Your Income & Expenditure

To enable the Trustees to assess your application, please provide the following information. This should include details of all sources of income and expenditure per month. If your income or expenses are received on a weekly basis, multiply that amount by 4.33 to obtain the monthly average. On the other hand, if the income or expenses are calculated on a yearly basis, divide the total by 12 to determine the monthly value.

Pensions/Salary

1. Wages/Salary

2. State Retirement Pension

3. Pensions paid by a past employer

4. Private Pension

5. Widow’s Pension

6. Any other pension

7. Any other income

Social Security Benefits

1. Universal Credit

2. Pension Credit

3. Housing Benefit

4. J.S.A.

5. E.S.A.

6. P.I.P.

7. Any other benefits

Other Assets

1. Annuities

2. Bank Deposit Account

3. Building Society Account

4. Investment

5. Premium Bonds

6. Rental from property or land you own

7. Insurance Policies

8. Funeral Plan

9. Grants from a charity

10. From a trust fund

11. Financial assistance from friend/ relative

12. Any other income – please give details

TOTAL INCOMINGS (Please Enter Sum of Your Income & Expenditure)

EXPENSES/OUTGOINGS

Rent

Council Tax

Utilities

Food

Household/Cleaning

Cigarettes/Alcohol/ (Please specify)

Leisure/Entertainment (Please specify)

Insurance

Travel Costs

Mobile phone

Telephone/Broadband

TV Licence

Clothing

Catalogue

Credit Cards

Loans

Other

TOTAL EXPENSES (Please Enter Sum of Your EXPENSES/OUTGOINGS)

(The Trustees will ask for photocopies of pages of passbooks/bank/building society statements/pay slips etc.)

Do you own a car?

Yes

If yes please give details:

Make

Model

Vehicle Registration Plate

Section 6 – About your Health and Social Factors

Name & Address of your doctor:

Telephone Number

Are you able and willing to live independently and to look after yourself and your accommodation?

Please give details of any significant illnesses, injuries or operations during the last five years

Section 7 – References

Please give the names and addresses of two responsible people (not relatives) who know you well and whom the charity may approach for a reference.

If you are currently renting accommodation, one of the referees should be your current or former landlord. Please indicate how you know the referees.

MR/MRS/MS/MISS

Name

Post-code

Telephone no

Mobile no

Relationship to you

MR/MRS/MS/MISS

Name

Post-code

Telephone no

Mobile no

Relationship to you

Section 8 – Other information

How did you hear of Jesus Hospital Charity and have you applied anywhere else for housing. If so, please give details?

If there is any further information which you would like the Visitors to take into account while considering your application, please give it briefly below.

Section 9 – Declaration

I have read the charity’s Conditions of Entry and believe I am eligible to apply to live in one of the Charity’s almshouses.

I declare the information given in this application is correct and complete to the best of my knowledge and belief.

I understand the Trustees would be entitled to terminate any appointment to an almshouse dwelling I may be given if my answers in this application form are untrue, or misleading in any respect (for example, due to omitting or misstating relevant facts).

I have read and understood this application form and information sheet provided and agree to abide by the terms and conditions stated therein should I be appointed to an almshouse.

I accept that if I am appointed as a resident, I shall be a beneficiary of the charity and not a tenant. Any weekly sum I pay will be a maintenance contribution and not a rent.

I confirm that I am able to look after myself and to live independently, with the assistance of family and social services if necessary.

I consent to my GP or other medical attendant providing the charity with a medical certificate or report about my health and condition now or at a future date in accordance with the terms of the attached form of authority.

I consent to the charity holding personal data on this form in accordance with Data Protection Regulations.

I agree the charity may contact me by: (Please tick as appropriate)

Post

Telephone

Signature

Name

(PLEASE PRINT NAME IN CAPITAL LETTERS)

Date

MM slash DD slash YYYY