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Application for Social Housing Transfer Applicants must hold

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Application for Social Housing Transfer
A transfer application will not be considered unless the following conditions are met:
Applicants must hold tenancy in present accommodation for a period of at least two years.
Applicants must have a clear rent account for a period of 6 months prior to date of application.
Current accommodation must be in a satisfactory condition, subject to Council inspection.
Applicants must have no record of anti-social behaviour.
Details of others in household in addition to applicant(s) named above:
Name Gender Date of Birth Relation to Applicant Occupation
1. _____________________________________________________________________________________
2.______________________________________________________________________________________
3.______________________________________________________________________________________
4.______________________________________________________________________________________
5._______________________________________________________________________________________
Reason for transfer request: (If medical reasons, you are required to complete the attached HMD-Form 1)
Downsizing Overcrowding
Medical Other
A transfer application will normally only be considered on grounds of downsizing, overcrowding or medical
requirements. If there are other exceptional reasons, please briefly explain below and supply supporting
documentation if required.
__________________________________________________________________________________
__________________________________________________________________________________
Tenant A
1. Name ______________________
2. Address ______________________
______________________
______________________
3. Contact no. ______________________
Tenant B
1. Name ______________________
2. Address ______________________
______________________
______________________
3. Contact no. ______________________
Please tick a maximum of 3 areas to which you would like to be transferred to:
Clarecastle
Kilmihil
Lisdoonvarna/Ballyvaughan
Clonlara
Kilfenora
Miltown
Malbay/Mullagh/Quilty
Cooraclare/Doonbeg
Kilmaley
Meelick/Parteen/Westbury
Corofin/Ruan
Killaloe
Newmarket On Fergus
Ennis
Kildysart/Ballynacally
Quin
Ennistymon/Lahinch
Kilkee/Cross/Carrigaholt
Sixmilebridge
Feakle/Scariff/Whitegate
Kilrush Town
Shannon
Tulla/Kilkishen/Broadford
N.B. Any alterations carried out to the dwelling/apartment become the property of Clare County Council and are
not removable by the tenant upon termination of the tenancy nor is any compensation payable in respect of these
alterations.
Please ensure the following documents are included where applicable:
Birth certificates and PPSNs for any additional household members not previously submitted.
If applying on medical grounds you must complete the attached HMD-Form 1
If transfer is requested because of exceptional circumstances, supporting documentation should be
submitted to support your application.
Please read this declaration carefully and sign and date it when you are satisfied that you understand it. Please note that an application will
only be accepted when this declaration has been signed.
Collection and Use of Data
The housing authority will use the data which you have supplied to assess and administer your housing application. Data may be shared with
other public bodies for the purpose of the prevention or detection of fraud. The housing authority may, in conjunction with the Department of
the Environment, Heritage & Local Government, process this data for research purposes including forward planning in relation to the
assessment of housing needs.
The housing authority may, for the purposes of its functions under the Housing Acts of 1966-2009, request and obtain information from
another housing authority, the Criminal Assets Bureau, An Garda Siochana, The Department for Social Protection, the Health Service Executive
(HSE) or an approved housing body, in relation to occupants or prospective occupants of, or applicants for, local authority housing, and any
other person the authority considers may be engaged in anti-social behaviour.
Clare County Council Housing Privacy Policy is available on our website https://www.clarecoco.ie/[info]/privacy-statement/default.html.
Declaration
I/We declare that the information and particulars given by me/us on this application are true and correct.
I/We undertake to notify the Housing Authority of any change in my/our household circumstances (eg. Address, household composition,
employment, medical conditions etc.)
I/We also authorise the housing authority to make whatever enquiries it considers necessary to verify details of my/our application.
I/We am/are aware that the furnishing of false or misleading information is an offence liable to prosecution.
Signed: [Applicant]
Date: [dd/mm/yy]
_ _/ _ _/ _ _
Signed: [Applicant 2]
Date: [dd/mm/yy]
_ _/ _ _/ _ _
1 Disability and/or Medical Information Form
HMD – Form 1
Disability and/or
Medical Information Form
About this form
This form is for anyone who is applying for social housing or a social housing transfer
due to a disability or medical grounds. The information provided will be used to
assess if priority status should be awarded to an application.
What is priority status and who we give it to
When we give a person priority status on disability or medical grounds, this means
they go nearer to the top of the waiting list, as set out in the Local Authority’s
Allocation Scheme.
Priority status may be awarded if the following three criteria apply to your household:
• you or someone in your household has a disability or a medical condition and
• the current accommodation is not suitable to meet the needs of the person
with a disability or medical condition and
• a change in housing will improve or stabilise the circumstances of the person
with a disability or medical condition.
Who needs to ll out and sign each section of this form
Section 1 and 2 to be lled out and signed by the person with a disability or medical
condition or by the applicant for social housing support if the person with a disability
or medical condition is a dependant of the applicant.
Section 3 and 4 to be lled out by two Healthcare Professionals who work
with the person with a disability or medical condition.
Other information
A Healthcare Professional includes the following professions: Consultant, General
Practitioner (GP), Mental Health Nurse, Public Health Nurse, Occupational Therapist
and Social Worker. If you are considering using a Healthcare Professional not listed
above, please contact your Local Authority to conrm if this is acceptable.
An Occupational Therapist report must be provided where there is a need for
a specic accommodation requirement.
If you require extra space to complete the form please include additional pages.
2 Disability and/or Medical Information Form
Section 1: Disability and/or Medical Information
This section must be lled out by the applicant.
Please tick (✓) the box to show the category you are applying under.
Disability grounds Medical grounds
Please state your disability and/or medical condition
If you are a person with a disability, please tick (✓) which category of disability
applies to you.
Physical SensoryMental Health Intellectual
Section 2: Personal Details
This section must be lled out as outlined on page 1. Please make sure the details
you ll out here are the same as on your Social Housing Application Form.
Please ll in the details of the main housing applicant below.
First name Surname
PPS number Date of Birth
Declaration
I permit the Healthcare Professionals in Section 3 to give relevant medical details
to the Local Authority to identify my housing needs.
Signature Date
3 Disability and/or Medical Information Form
If the person with a disability or medical condition is not the main housing applicant,
please ll in their details below.
First name Surname
PPS number Date of Birth
Section 3A: Medical Reference
This section must be lled out by two Healthcare Professionals (see page 1)
who work with the person with a disability or medical condition.
Details of Healthcare Professionals completing this form
Healthcare Professional 1
First name Surname
Name of organisation Telephone
Email
Please indicate the professional service you provide to the person with a disability
or medical condition.
Please tell us the total length of time the person with a disability or medical condition
has been receiving your service.
One consultation
only
Weeks
(number)
Months
(number)
Years
(number)
4 Disability and/or Medical Information Form
Healthcare Professional 2
First name Surname
Name of organisation Telephone
Email
Please indicate the professional service you provide to the person with a disability
or medical condition.
Please tell us the total length of time the person with a disability or medical condition
has been receiving your service.
One consultation
only
Weeks
(number)
Months
(number)
Years
(number)
Section 3B: Applicant’s Current Accommodation
This section must be lled out by two Healthcare Professionals who work with the
person with a disability or medical condition.
Is the person with a disability or medical conditions current accommodation directly
or negatively affecting their disability or medical condition? If the answer is yes,
please explain below.
Healthcare Professional 1
5 Disability and/or Medical Information Form
Healthcare Professional 2
Section 3C: Accommodation Need of Applicant
This section must be lled out by two Healthcare Professionals who work with the
person with a disability or medical condition.
How would a change in location of accommodation benet the person with
a disability or medical condition?
Healthcare Professional 1
Healthcare Professional 2
6 Disability and/or Medical Information Form
What change in the type of accommodation would benet the person with a disability
or medical condition? and how?
Healthcare Professional 1
Healthcare Professional 2
What change in the design of accommodation would benet the person with a
disability or medical condition? and how?
Healthcare Professional 1
Healthcare Professional 2
7 Disability and/or Medical Information Form
Section 3D: Support Needs for the Applicant
This section must be lled out by two Healthcare Professionals who work with the
person with a disability or medical condition.
Are supports currently needed to enable the person with a disability or medical
condition to live independently? Please provide details.
Healthcare Professional 1
NoYes
Healthcare Professional 2
NoYes
Will the person with a disability or medical condition need any additional or new
supports? Please provide details.
Healthcare Professional 1
NoYes
Healthcare Professional 2
NoYes
8 Disability and/or Medical Information Form
Section 4: Healthcare Professional Declaration
Healthcare Professional 1
I declare that the information and details I have provided on this form are correct
and true.
I agree to the Local Authority contacting me, if necessary, to verify the details
I have provided.
Signature Date
Healthcare Professional 2
I declare that the information and details I have provided on this form are correct
and true.
I agree to the Local Authority contacting me, if necessary, to verify the details
I have provided.
Signature Date
If you require extra space to complete the form please include additional pages.
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Completed 1 October 2021

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