Home Improvement Assistance Application Form

Private and Confidential
HIA1 (v3)
Please return this form to:Private Sector Housing Team
Knowsthorpe Gate
Cross Green
Leeds
LS9 0NP
Tel: 0113 395 7151
Housing Partnerships
Housing Services
Home Improvement Assistance
Application Form
PLEASE READ CAREFULLY THE ACCOMPANYING LEAFLET
BEFORE FILLING IN THIS FORM.
PLEASE ANSWER QUESTIONS IN CAPITAL LETTERS
OR CIRCLE THE RELEVANT ANSWERS.
1. Address Details
Address of property at which the works are to be carried out:
Address for correspondence (if different):
Postcode:
Home Telephone Number:
Work/Mobile Telephone Number:
E-mail Address:
Postcode:
Home Telephone Number:
Work/Mobile Telephone Number:
E-mail Address:
2. Ownership Details
Full name(s) of person(s) having ownership interest in the above said property.
Title
Forename
Surname
Age
Date of
Birth
Owner Status
Owner Occupier/
Joint Owner
Owner Occupier/
Joint Owner
Owner Occupier
/ Joint Owner
Address if different from
above
3. Other people who live with you
Title
Forename
Surname
Age
Date of
Birth
What do they do? (eg
school, unemployed,
work, student, retired)
Relationship to
Owner(s)
4. Benefits Details
Are you or any of the applicants in receipt of any of the following (please circle as appropriate):
Income Support
Guaranteed Pension Credit
Income Based Job Seekers Allowance
Employment & Support Allowance (Income-Related)
Council Tax Benefit (not single person discount)
Housing Benefit
Working Tax Credit (income limits apply)
Child Tax Credit (income limits apply)
Disability Living Allowance
Attendance Allowance
Industrial Injuries Disablement Benefit
War Disablement Pension
Please note on visiting an officer will ask you to provide proof of your related benefits.
06/2011
5. Property Details
Type of property (Please circle):- Detached
Semi-Detached
Through Terrace
End Terrace
Back to Back
When did you buy the property? __________________________________________________________________
What Council Tax Band is your property in?
A
B
C
D
E
F
G
H
Don’t Know
Is there loft insulation? Yes
No
If yes, please describe type and thickness ___________________________________________________________
Is there central heating? (please circle) Yes No
If yes, type of fuel ______________________________________________________________________________
Have you got smoke alarms? (please circle) Yes
No
Do you consider your home secure? (please circle) Yes
No
If no, explain why?______________________________________________________________________________
What is the approximate value of your property? £____________________
Do you have a mortgage? (please circle)
Yes
No
What type of Mortgage do you have? (please circle)
Repayment
Mortgage Start Date:
Original Amount Borrowed:
____________________
Any Further Borrowing (on Mortgage)?
Yes
Date:
Amount:
____________________
Do you have up-to date buildings insurance cover?
If Yes, which company is it with?
Endowment
Interest Only
£____________________
No
£____________________
Yes
No
____________________________________________________
MORTGAGE DETAILS:
Mortgage Lender Name: _______________________________________________________________________
Account No. :
___________________________________________
Actual Monthly/ Weekly Payment: £___________________
Arrears (if any): £___________________
Approx. Balance Outstanding: £___________________
ENDOWMENT POLICY DETAILS:
Endowment Policy Company Name: ____________________________________________________________
Policy Number:
________________________________________________
Monthly Premiums: £___________________
Is the policy tied to your property? (please circle)
Is your Policy? (please circle)
Live
Yes No
Surrendered
Lapsed
Please note on visiting an officer will ask you to provide your most recent Mortgage
Statement.
SECURED LOAN DETAILS:
Secured Lender Name: _______________________________________________________________________
Account No. :
__________________________________________
Start Date: __________________
Type (please circle):
Repayment
Amount Borrowed: £____________________
Interest Only
Purpose: __________________________________________________________________________
Actual Monthly/ Weekly Payment: £____________________
Arrears (if any): _________________
NB: If you have more than 1 Secured Loan, please continue on a separate sheet of paper.
UNSECURED LOAN DETAILS:Loan details:
___________________________________________________________________________________
Account No. :
__________________________________________
Start Date: __________________
Total Borrowed: £____________________
Period:
_______________________________________________
Purpose: __________________________________________________________________________
Actual Monthly/ Weekly Payment: £____________________
Arrears:
£____________________
NB: If you have more than 1 Unsecured Loan, please continue on a separate sheet of paper.
Credit Card/Store Card details
Credit Cards/ Store Cards details:
___________________________________________________________________________________
Start Date: __________________
Amount Borrowed: £____________________
Actual Monthly/ Weekly Payment: £____________________
Balance:
£____________________
Credit Limit:- £____________________
NB: If you have more than 1, please continue on a separate sheet of paper.
Please note on visiting an officer will ask you to provide any approved Loan Agreements.
06/2011
6. Repair/Improvement Details
Are the works likely to cost more than approx. £1,000?
Yes
No
Please give a brief description of what works are required at your property:
7. Declaration and Signatures
Public funds must be protected and so the information you have provided on this form may be used to prevent and
detect fraud.
The information may also be shared, for the same purposes, with other organisations which handle public funds.
I declare that the information I have given is correct and complete. I fully understand that if false information is given this
will result in my enquiry being cancelled or court proceedings possibly being taken to recover any payments made.
You authorise us to write to your existing lender(s) for consent to register the Legal Charge and to obtain your title
deeds from them where necessary.
You agree to let us know if any of your circumstances described in this form change after you complete this application
form.
You agree to provide the title deeds where necessary if your property is unencumbered (no mortgage no secured loans)
I accept that financial assistance will be based on the lowest estimate submitted from my contractors.
I accept that if there are any structural problems with my property that, where relevant, I will contact my
buildings insurance company in the first instance.
Signed (yourself): ...........................................................................................................................................
National Insurance Number: ........................................................................... Date: ........../........../..........
Signed (partner): ...........................................................................................................................................
National Insurance Number: ........................................................................... Date: ........../........../..........
FOR OFFICE USE ONLY
I ...................................................................................... have completed this form on behalf of the applicant and have
read all the details over to him/her before asking him/her to sign the declaration.
Signature: ....................................................................................................... Date: ........../........../..........