Application form - Alms Houses

Only Applications from those residing within the Parishes of Kingsclere and Ashford Hill with Headley can be considered.

Please do not apply if you do not meet this requirement.

Data Protection Statement.

It is part of the Trustees' responsibilities to ensure that applicants for the Almshouses are suitably qualified under the terms of the Charity's Governing Document. Trustees, therefore, will need to investigate the personal circumstances of all applicants. The Charity complies with the regulations for Data Security - General Data Protection Regulations (GDPR). The data we collect has been classified as Sensitive Data under Article 9 of GDPR. We have strong procedures and policies in place to protect the collection and storage of this data. The personal data supplied on the form and other information relating to the Almshouse Appointment or your care management will be held on file. Some details may be checked with relevant organisations since the Charity reserves the right to investigate and verify what you write on this form, but no details will be disclosed for any inappropriate purpose. You may have access to your personal information on request.

Section 1 - About You (First Applicant)

Title *

First Name *

Surname *

Address *

Length of Time at this Address *

Telephone Number *

Mobile Phone Number *

Your email address *

Date of Birth *

Marital Status *

Employment History. Please give details of your current occupation (if any), hours of work and brief details of your employment history. You will be required to bring evidence of earnings such as payslips or proof of earnings (if self employed) to interview. *

Section 1 - Second Applicant (if not applicable please mark NA in each of the boxes).

Title *

First Name *

Surname *

Address *

Length of time at this address. *

Telephone Number *

Mobile Phone Number *

Email address *

Date of Birth *

Marital Status *

Section 2 - About your family.

Next of Kin *

Relationship *

Address of your next of Kin *

Telephone Number *

Mobile Number *

Email address *

Section 3 - About your present home

Type of Accommodation (ie 3 Bedroom house, flat..) *

Do you or your spouse own the property? *

If Yes, what is the current estimated value?

What is the Council Tax Band for this property? *

Is there a mortgage outstanding on this property? *

If yes, how much is outstanding? If there is no mortgage, please write 'None"

If you do not own the property where you currently live, who is the owner of this property? *

Is this person related to you in any way? *

If Yes, what is the relationship? *

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

If rented, please give the name and address of the landlord. *

If rented, what is the current rent per week?

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

Do you receive Council Tax discount or reduction? *

Why do you wish to leave your present accommodation? *

What are your intentions regarding your current accommodation if you are appointed to an almshouse? *

If you or your partner own property other than the one in which you live now, please give the address details including the Post Code. This should include property owned abroad as well as in the UK. *

Section 4 - Your income

To enable the trustees to assess your application, please provide the following information. This should include details of all sources of income and state how frequently you receive them, ie weekly, monthly or annually.

Pensions

State Pension

Frequency *

Pension paid by a past employer

Frequency *

Private Pension

Frequency *

Any other pension

Frequency *

Benefits

Please list all benefits received ie Universal Credit, PIP, housing benefit etc and the amounts paid per month *

Other Income

Please state and detail any other income received ie Annuities, Investments, financial assistance from a relative and friend and the amounts paid per month.

Savings and Investments - and the amounts paid per month

Section 5 - About your health and social factors.

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

Please give details of any significant illnesses, injuries or operations during the last 5 years. *

Are you currently receiving treatment for any illnesses? *

If Yes, please give details:

Are there any other health or social factors that you would wish the trustees to take into consideration when assessing your application? *

If yes please give details:

Please give the name and full address of your GP.

GP's Name *

GP's Surgery address *

The charity may wish to write to your GP to ask them to complete a medical certificate to enable your application to be considered further. If you are appointed as a resident and, at a later date the trustees become concerned about your health and/or your ability to continue to live independently they may need to obtain a further medical report.

By signing this form you consent to the charity contacting your GP to authorise them to provide us with medical information about you either now or in the future.

Do you have a conviction which is not spent under the Rehabilitation of Offenders Act 1974? *

This information will be processed solely for the purposes of this application.

Section 6 - References

Please give the names and contact details 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 landlord.

Please indicate how you know the referees. We will never disclose sensitive personal data to the referees, but we will supply them with basic information regarding you and your application.

Referee 1.

Name of your Referee *

Referee Address *

Referee Contact Phone Number *

Referee Email address *

How do you know the referee? *

Referee 2.

Referee Name *

Referee Address *

Referee Contact Phone Number *

Referee Email Address *

How do you know the referee? *

Section 7 - Declaration

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

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

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

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 and sensitive data relating to me and my personal circumstances in accordance with the General Data Protection Regulations (GDPR).

I understand that I have the right to request access to information that is held by the Charity relating to my data. I understand that I have the right to decline to provide information requested within this form.

The Charity is obliged to check the immigration status of prospective residents and will need to see proof of identity such as a passport or driving licence.

I agree that the charity may contact me, my preference for contact is by: (please tick as appropriate.) *

Email
Post
Telephone
Mobile Phone

Signature *

Date signed *

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Application form - Alms Houses

Section 1 - About You (First Applicant)