One and Two Bedroom Units Available in Tasmania
35 Tower Road NEW TOWN 7008 GPO BOX 62 HOBART TAS 7001 Ph: (03)6208 6069 fax: (03)6208 6099
1|Page Centacare Tasmania Community Housing Association – Application for Housing
October 2011
You will need to bring the following information at the time of interview •
Proof of Identity (Driver’s License, Birth Certificate, Passport)
•
Proof of Income details and proof of assets for all household members
•
Letters of Support etc
Please tick your preferred locality and accommodation type
One Bedroom Units
Two Bedroom Units
26A Freesia Cres, Kingston
26A Freesia Cres, Kingston - 2 only
38 Balmoral Rd, Kingston Beach
106 Pomona Rd, Riverside
24 Torrens St, Richmond
10 Butler Ave, Riverside
2 Turriff Lodge Dr, New Norfolk
2 Butler Ave, Riverside
65 Williams St, Westbury
7 Friary Crt, Riverside
46 Mooreville Rd, Burnie
4 Friary Crt, Riverside 23 Suncrest Pl, Ravenswood 4 Seymour St, Ravenswood 21-23 Arthur St, Evandale 242 St Leonards Rd, St Leonards 23 York St, Wynyard 25 York St, Wynyard
2|Page Centacare Tasmania Community Housing Association – Application for Housing
October 2011
1. Applicant One
Mr
Miss
(To be completed by the person who would become the lease holder)
Mrs
Ms
Male
Female
Date of Birth:
____________________________
Surname:
_____________________________________________________________________
Given Names:
_____________________________________________________________________
Current Address: _____________________________________________________________________ Postal Address:
_____________________________________________________________________
Telephone No:
____________________________
Email Address:
_____________________________________________________________________
Mobile:
___________________________
Single Married De Facto Separated Divorced Widowed Other Drivers License No:___________________ Centrelink Reference No:________________________ Do you identify as an Aboriginal or Torres Strait Islander?
Yes
No
Are you a permanent resident of Australia?
Yes
No
What is your Country of birth? _________________________________________________________ Do you require an interpreter?
Yes
No
If yes what is your preferred language? _________________________________________________ Have you been homeless in the last 12 months?
Yes
No
Have you been in sheltered accommodation in the past 12 months? Yes
No
3|Page Centacare Tasmania Community Housing Association – Application for Housing
October 2011
2. Applicant Two
Mr
(To be completed by the person who would become a joint lease holder e.g. husband, wife, de facto, etc)
Miss
Mrs
Ms
Male
Female
Date of Birth:
____________________________
Surname:
_____________________________________________________________________
Given Names:
_____________________________________________________________________
Current Address: _____________________________________________________________________ Postal Address:
_____________________________________________________________________
Telephone No:
____________________________
Email Address:
_____________________________________________________________________
Mobile:
___________________________
Single Married De Facto Separated Divorced Widowed Other Drivers License No:___________________ Centrelink Reference No:________________________ Do you identify as an Aboriginal or Torres Strait Islander?
Yes
No
Are you a permanent resident of Australia?
Yes
No
What is your Country of birth? _________________________________________________________ Do you require an interpreter?
Yes
No
If yes what is your preferred language? _________________________________________________ Have you been homeless in the last 12 months?
Yes
No
Have you been in sheltered accommodation in the past 12 months? Yes
No
4|Page Centacare Tasmania Community Housing Association – Application for Housing
October 2011
3. Other Household Members
Please provide details of all other people who will live with you. This includes dependent children, carers, and friends Name
Gender
Date of Birth
Relationship to you
Income
________________
__________ ____________
_________________________
_______________
________________
__________ ____________
_________________________
_______________
________________
__________ ____________
_________________________
_______________
________________
__________ ____________
_________________________
_______________
________________
__________ ____________
_________________________
_______________
________________
__________ ____________
_________________________
_______________
4. Current Housing
What type of housing are you currently living in?
Private Rental
Public Housing
Homeless
Refuge
Community Housing
Boarding House
Family or Friends
Hostel
Hospital
Institutional Setting
Other (Please specify)
_______________________________________________________________________________________ _______________________________________________________________________________________ How many bedrooms does your current property have?
1
Do you live alone?
Yes
2
3
No
If no who lives with you? _______________________________________________________________ What is your weekly rent?
___________________________ 5|Page
Centacare Tasmania Community Housing Association – Application for Housing
October 2011
Are you behind in your rent?
Yes
No
(This will not necessarily impact on your application)
If yes, how much are you behind and why?_____________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ If you are in temporary, short or medium term accommodation, how much longer can you stay?
___________________________
Please list any previous Tenancies: Address:
Year:
Name on Lease:
Reason for leaving:
_________________________ _____
_________________________
__________________________
_________________________ _____
_________________________
__________________________
_________________________ _____
_________________________
__________________________
5. Current Household Income
Please show all current income sources received by you and all other house hold members. This includes income from wages, Centrelink, Pensions, Family Tax Payments, superannuation, maintenance, interest etc Person
Income Source
Gross Fortnightly Income
Total You will need to supply evidence of income for the entire house hold and attach to this application. 6|Page Centacare Tasmania Community Housing Association – Application for Housing
October 2011
6. Debts
Please provide details of any debts your or a household member currently has? Name:
Who is owed:
Fortnightly repayments:
7. Assets
Please show the total value of your and other household member’s current and pending financial assets (e.g. cash, savings, shares, investments, lump sum payments, rollovers etc) Person
Source of Financial Asset
Asset Value
8. Property/Land Please show details of land / residential premises currently owned or being purchased by yourself or other household members. This includes property being purchased in Australia and overseas and any property you have a legal right to, or interest in. Person
Address
Value
Mortgage
7|Page Centacare Tasmania Community Housing Association – Application for Housing
October 2011
9. Medical and Health Conditions
Do you or any member of your household have a medical or health condition? Yes
No
If yes, please provide details. If you have any supporting documentation please attach to your application. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Do you or anyone living with you have a disability?
Yes
No
Physical (e.g. stroke, cerebral palsy, arthritis, paraplegic)
________________________________
Intellectual
________________________________
Mental Health Illness (includes depression)
________________________________
Sight / Hearing Impaired
________________________________
10. Pets
Do you have any pets?
Yes
No
If yes, what type of pets?_______________________________________________________________ 1 11. References
Please list two rental references, including their contact details: Referee Name:
Contact No:
Relationship to this person
8|Page Centacare Tasmania Community Housing Association – Application for Housing
October 2011
12. Next of Kin
Please provide a contact for your Next of Kin who can also act as a contact for you. Name:____________________________________
Relationship to you:____________________
Address:______________________________________________________________________________ _______________________________________________________________________________________ Telephone:______________________________
Mobile:________________________________
13. Additional Information
Is there any additional information you would like to add?
Yes
No
If yes:_________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Do you have a public guardian or an authorised signatory?
Yes
No
If you answered yes, please provide their contact details: Name:________________________________________________________________________________ Address:______________________________________________________________________________ _______________________________________________________________________________________ Telephone No:______________________________
Mobile:________________________________
9|Page Centacare Tasmania Community Housing Association – Application for Housing
October 2011
14. Information on Privacy
Centacare Tasmania is committed to ensuring that all clients who use our services are treated with respect and dignity and to the protection of your person information. Centacare Tasmania adheres to the National Privacy Principles as set out in the Privacy Act 1988. Centacare Tasmania is also bound to protect your privacy to comply with contractual requirements with a range of Government Agencies. Under the Privacy Act 1988, you have certain rights in regard to the protection of your personal information and you will be asked to give written consent for the collection and disclosure of this information. You are entitled to access the information you provide. Please ask if you would like to read more about our privacy policy. If you are unhappy with the service you receive from Centacare Tasmania, you have the right to lodge a grievance. Grievance forms are available from all Centacare Tasmania offices State Wide. If you would like a member of your family to discuss your application you will need to provide written consent and attach to this application form.
CLIENT PRIVACY AGREEMENT – AUTHORITY TO COLLECT INFORMATION I give my consent for Centacare Tasmania to take personal information for the specific purpose of extracting statistical data in relation to their reporting requirements for their funding agreements. It is my further understanding that all information will be treated with full professional confidentiality and with due regard to the requirements of the Privacy Legislation 1988. Applicants Name:
________________________________________
Applicants Signature:
________________________________________
10 | P a g e Centacare Tasmania Community Housing Association – Application for Housing
October 2011
15. Declaration
I / We state that the information provided in this application is true and correct in every detail and acknowledge that providing false information would be grounds to cancel the application or end any tenancy arising from it. Applicant 1:_____________________________
Applicant 2:___________________________
Witness:
Witness:
_____________________________
___________________________
Print Witness Name:____________________________________________________________________ Date:
_____________________________
11 | P a g e Centacare Tasmania Community Housing Association – Application for Housing
October 2011
When called in for an interview please have the following documents available.
Copies of: Centrelink Income Statement/s
Other income statement/s if relevant
Proof of citizenship if relevant
Details of financial assets
Proof of Identity: Drivers Licence/s
Birth Certificate/s
Passport/s
Letters of support and additional information if relevant
Please return this form to: Housing Manager Centacare Tasmania PO BOX 62 Hobart TAS 7009 Or Email: ctcha@aohtas.org.au
12 | P a g e Centacare Tasmania Community Housing Association – Application for Housing
October 2011