Decant Policy
Appendix 2 - Housing decant form
Please fill in this form carefully and clearly. When completed, please return it to the housing office / Customer Care Officer. You can also contact the housing office if you need help completing the form.
YOU AND YOUR HOUSEHOLD | ||||||
Your Title: | ☐ Mr | ☐ Mrs | ☐ Miss | ☐ Ms | ||
☐ Other: (please specify) | ||||||
Surname: |
| First Name: |
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Date of Birth: |
| Age: |
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Employment Status: |
| National Insurance Number: |
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Current Address: |
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| Postcode: |
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Telephone (Home): |
| Telephone (Mobile): |
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Other: |
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TENANTS WITHIN YOUR HOUSEHOLD | ||||||
Please list everyone you live with: | ||||||
Surname | First Name | Date of Birth | Age | Sex | Relationship to You | Occupation |
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MEDICAL OR PHYSICAL NEEDS | ||
Do you, or any members of your household, have a medical or physical problem? Please answer all of the following questions: | ||
Does anyone in your household have a disability? | ☐ Yes | ☐ No |
Is anyone in your household registered disabled? |
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Does anyone in your household have any physical difficulties relevant to your housing situation? |
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Does anyone in your household need ground floor or another specific type of accommodation? |
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Is there anyone in your home who requires wheelchair adapted accommodation? |
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If you answered yes to any of these questions, please give details below: | ||
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PETS | ||
Does any member of your household have pets? | ☐ Yes | ☐ No |
If you answered yes, please give details below: | ||
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YOUR CURRENT HOME | ||
How long have you lived at your current address? | Years: ____ | Months: ____ |
What floor is your current home on? (please select) | Ground / 1 / 2 / 3 /4 | |
Number of bedrooms: | Bedsit / 1 / 2 / 3 / 4 / 5 | |
Is it a caravan? | Yes / No | |
Is it rented? | Yes / No | |
If rented, please provide details of the landlord: |
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YOUR HOUSING REQUIREMENTS | |
Please answer all of the questions below: | |
How many bedrooms do you need? | Bedsit / 1 / 2 / 3 / 4 / 5 |
Would you like to live in older persons accommodation? | Yes / No |
Do you need wheelchair adapted accommodation? | Yes / No |
Can you cope with a long flight of stairs? | Yes / No |
If you have children, if yes where do they go to school? Please state school name: _________________________ | Yes / No |
Do you have any other essential requirements? |
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ADDITIONAL INFORMATION |
Is there any other information you would like to add? For example, do you want to move to a specific area because you have family living there or you work in that area? |
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Name: ____________________________ Signature: ____________________________
Date: ____________________________
Declaration
Even if someone else has completed this form on your behalf, you must sign this declaration.
Please read the declaration below carefully before you sign and date it.
- I hereby declare the information given on this form is correct and complete to the best of my knowledge.
- I understand that under Section 214 of the Housing Act 1996 (opens new window) it is an offence to knowingly or recklessly make a statement which is false and/or withhold information in order to obtain assistance with housing.
- It is also an offence if you do not notify the council of any material changes in your circumstances as soon as possible.
- I am aware that if I give information that is incorrect or incomplete, the council may take action against me. This may include court action and anyone guilty of such an offence is liable, upon conviction, to a fine of up to £5,000.
Signed: ____________________________ Date: _____________________
Signed: ____________________________ Date: _____________________