Fillable Housing Assistance Application (Department of the Environment and Energy)

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Housing Assistance Application (Department of the Environment and Energy)

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Application No.
Housing assistance application
pursuant to the Housing Act 2003
Housing Assistance Application
A range of housing assistance options are available to help Queenslanders with their housing needs.
Options include private housing products, public, community and indigenous housing programs and referrals
to local service providers. This application collects essential information to assess eligibility for the Public,
Community, Aboriginal and Torres Strait Islander and Indigenous Council Housing Programs.
Im
portant information
Your eligibility for housing assistance will be assessed based on the information and the supporting
documentation you provide with this application. If your circumstances change at any time, please
notify your local Housing Service Centre within 28 days of the changes.
Completing this application – have you:
Answered all the questions with a tick where there are Yes/No boxes?
Collected evidence and supporting documentation including proof of income and assets for
each household member detailed in this application?
Read and signed the declaration and consent on the last page?
Had this application signed by a witness on the last page?
Alternatively, Housing Service Centre officers can witness this application if you are submitting it in
person.
Got identification ready for when you submit this application?
Alternatively, you can attach witnessed copies of your identification evidence if you are returning this
application via post.
For
more information on housing assistance, please call or visit your local Housing Service Centre.
Alternatively, you can access information at www.qld.gov.au
/housing or download our ‘Housing
Assist Qld’ mobile app from the Google Play, Microsoft or Apple App stores.
Housing Assistance Application
HAA 2.0 (180621) 2
Application Assistance
What is your first spoken language?
Do you need an interpreter? If you speak in a language other than English, or have hearing difficulties, we can
arrange for an interpreter to assist you.
Which interpreter do you require? Language, provide details:
Signing
Do you need assistance when
making decisions? Yes No
If yes, which of the following.
Public Trustee Family, Friend or Advocate
Office of the Public Guardian Power of Attorney
Other, provide details:
What type of housing would
you like to apply for? Social Housing Indigenous Council Housing
Public, Community and remote and discrete
Aboriginal and Torres Strait Islander
Household Contact Details
Full name:
Preferred contact method? Email Letter Telephone SMS
Current addr
ess:
Mailing address: As above
If different, detail below.
Telephone: Home: Mobile:
Work:
Email:
Alternative contact details? Name:
Address:
Telephone: Home:
Work:
Mobile:
This may be a person that helps you to
make decisions, or someone who makes
decisions on your behalf about your
personal, lifestyle or financial matters.
Provide details of an alternative contact
person the department could contact if
they were unable to contact you
directly. This may be a friend, relative
or an organisation
.
Tick all that apply.
Housing Assistance Application
HAA 2.0 (180621) 3
Household member/s details
Household member 1
Primary applicant full name:
Alias:
Gender: Date of birth: / / Country of birth:
Do you identify as: Aboriginal Australian South Sea Islander
Torres Strait Islander Other cultural or linguistic background None
Centrelink reference number (CRN):
Department of Veteran Affairs reference number (DVA):
Citizenship/Residency details: Australian citizen Permanent resident
Not permanent resident Visa - what type?
Are you expecting a child? Yes No
If yes, expected due date:
Do you have a medical
condition or disability? Yes No
If yes, provide details:
What is your income? $ Frequency: Type:
$ Frequency: Type:
What are your assets? $ Type:
$ Type:
Do you own/part own property
in Australia or over
seas? Yes No
If yes, what type:
Address:
% of property owned:
Current property value:
Ownership date:
What type of transport do
you use? Public Own Other (family and friends)
Any other name you may be known as.
Gross amount and type (wages,
pension, allowances, family
payments, interest, superannuation).
Savings, investments, cash deposits,
property trusts, shares, bonds,
debentures, superannuation - allocated
pension or lump sum payments, share
from property sale or settlement.
This could include residential, vacant
land, industrial property, commercial
property, live-aboard boat, cabin,
donga, caravan, or manufactured/
transportable home.
complete and attach ‘Additional household
member’ forms before submitting this application.
Tick all that apply.
Housing Assistance Application
HAA 2.0 (180621) 4
Household member 2
What is your relationship with Household member 1?
Full name:
Alias:
Gender: Date of birth: / / Country of birth:
Do you identify as: Aboriginal Australian South Sea Islander
Torres Strait Islander Other cultural or linguistic background None
Centrelink reference number (CRN):
Department of Veteran Affairs reference number (DVA):
Citizenship/Residency details: Australian citizen Permanent resident
Not permanent resident Visa - what type?
Are you expecting a child? Yes No
If yes, expected due date:
Do you have a medical
condition or disability? Yes No
If yes, provide details:
What is you
r income? $ Frequency: Type:
$ Frequency: Type:
What are you
r assets? $ Type:
$ Type:
Do you own/part own property
in Australia or overseas? Yes No
If yes, what type:
Address:
% of property owned:
Current property value:
Ownership date:
What type of transport do
you use? Public Own
Other (family and friends)
Any other name you may be known as.
Gross amount and type (wages,
pension, allowances, family
payments, interest, superannuation).
Savings, investments, cash deposits,
property trusts, shares, bonds,
debentures, superannuation - allocated
pension or lump sum payments, share
from property sale or settlement.
This could include residential, vacant
land, industrial property, commercial
property, live-aboard boat, cabin,
donga, caravan, or manufactured/
transportable home.
Tick all that apply.
Housing Assistance Application
HAA 2.0 (180621) 5
Household member 3
What is your relationship with Household member 1?
Full name:
Alias:
Gender: Date of birth: / / Country of birth:
Do you identify as: Aboriginal Australian South Sea Islander
Torres Strait Islander Other cultural or linguistic background None
Centrelink reference number (CRN):
Department of Veteran Affairs reference number (DVA):
Citizenship/Residency details: Australian citizen Permanent resident
Not permanent resident Visa - what type?
Are you expecting a child? Yes No
If yes, expected due date:
Do you have a medical
condition or disability? Yes No
If yes, provide details:
What is you
r income? $ Frequency: Type:
$ Frequency: Type:
What are you
r assets? $ Type:
$ Type:
Do you own/part own property
in Australia or overseas? Yes No
If yes, what type:
Address:
% of property owned:
Current property value:
Ownership date:
What type of transport do
you use? Public Own
Other (family and friends)
Gross amount and type (wages,
pension, allowances, family
payments, interest, superannuation).
Savings, investments, cash deposits,
property trusts, shares, bonds,
debentures, superannuation - allocated
pension or lump sum payments, share
from property sale or settlement.
This could include residential, vacant
land, industrial property, commercial
property, live-aboard boat, cabin,
donga, caravan, or manufactured/
transportable home.
Any other name you may be known as.
Tick all that apply.
Housing Assistance Application
HAA 2.0 (180621) 6
Household member 4
What is your relationship with Household member 1?
Full name:
Alias:
Gender: Date of birth: / / Country of birth:
Do you identify as: Aboriginal Australian South Sea Islander
Torres Strait Islander Other cultural or linguistic background None
Centrelink reference number (CRN):
Department of Veteran Affairs reference number (DVA):
Citizenship/Residency details: Australian citizen Permanent resident
Not permanent resident Visa - what type?
Are you expecting a child? Yes No
If yes, expected due date:
Do you have a medical
condition or disability? Yes No
If yes, please provide details:
What is you
r income? $ Frequency: Type:
$ Frequency: Type:
What are you
r assets? $ Type:
$ Type:
Do you own/part own property
in Australia or overseas? Yes No
If yes, what type:
Address:
% of property owned:
Current property value:
Ownership date:
What type of transport do
you use? Public Own
Other (family and friends)
Gross amount and type (wages,
pension, allowances, family
payments, interest, superannuation).
Savings, investments, cash deposits,
property trusts, shares, bonds,
debentures, superannuation - allocated
pension or lump sum payments, share
from property sale or settlement.
This could include residential, vacant
land, industrial property, commercial
property, live-aboard boat, cabin,
donga, caravan, or manufactured/
transportable home.
Any other name you may be known as.
Tick all that apply.
Housing Assistance Application
HAA 2.0 (180621) 7
Your need to move
Does your household need to move for any of the following reasons?
You are experiencing or at risk of
domestic and family violence
You are in crisis housing
provided by a homelessness
service
You need to meet your or a
household member’s disability
support needs
You are experiencing or at risk of
violence, abuse or harassment
from a household or community
member
You are staying temporarily with
family and/or friends and have no
other housing to go to
You are a long-term patient in a
hospital or health facility and are
ready to be discharged
You have the safety of a child in
your care at risk
You are living on the street, in a
car or park, makeshift shelter or
illegal building
You are experiencing a family or
relationship breakdown
You are in or have just been
released from prison
You are living in a boarding
house, caravan park or hostel
that has or is about to be closed
You pay more than 30% of your
gross household income in rent
You are a young person (under
25 years old) currently in, exiting
or exited State care
You are being evicted or about to
be evicted
Your housing has been impacted
by a natural disaster
You are a young person in,
exiting or exited a Youth
Detention Centre
You are a victim of major crime
that was committed in
Queensland
Is your current housing location unsuitable for any of the following reasons?
Too close in proximity to the
perpetrator of domestic violence
against you
Too far away from education or
training services
Does not enable family
reunification
Does not meet the conditions of a
Court Order, Parole or Probation
Order, Family Court Order,
Domestic Violence Order, Child
Protection Order
Too far away from frequently
required essential services –
transport, medical, disability
support for daily activities,
transport to meet mobility
requirements
Does not enable you to gain or
maintain regular access or
custody to shared care of
children
Too far away from family and
community support which
impacts on the wellbeing of the
household
Distance does not allow you to
accept a firm offer of employment
– minimum 20 hours per week
You are an Aboriginal or Torres
Strait Islander person and need
to move for cultural reasons
Is your current housing unsuitable for any of the following reasons?
Design restricts daily living
activities – bathing, mobility, or
seriously aggravates a medical
condition or disability
Size too small resulting in
overcrowding
Health and safety issues due to
lack of essential facilities or poor
structural conditions
Note: Co-applicants need have their individual current housing deemed unsuitable to be eligible for social housing.
Tick all that apply.
Tick all that apply.
Tick all that apply.
Housing Assistance Application
HAA 2.0 (180621) 8
How much rent does the household currently pay per week?
Is everybody listed on this application currently living with you? Yes No
What type of accommodation is the household currently living in?
Your financial wellbeing
Are you or another applicant experiencing any of the following situations?
Unable to work and have high
levels of living expenses beyond
normal living costs related to a
long-term or serious medical
condition, or permanent and/or
significant disability
Multiple periods of
unemployment
Long-term unemployment
Currently employed –
Part-time
Full-time
Casual
Your wellbeing
Have any of the following affected you or your household’s ability to access stable housing?
You or a household member
have a permanent and significant
disability
Multiple unsuccessful private
rental applications
You have a history of
homelessness
You or a household member
have a long-term or serious
medical condition
A limited number of or no suitable
properties to meet needs - size,
location or features
Your safety is at risk
You are experiencing or at risk of
violence, abuse or harassment
from another person or
community member
You have been evicted multiple
times in the past three years for
rent arrears, disruptive
behaviour, relationship
breakdown or property damage
You are a young person at risk
who requires a tailored response
on your path to independence
Tick all that apply.
Tick all that apply.
Such as private rental, own home, caravan,
boarding house, temporary housing.
Housing Assistance Application
HAA 2.0 (180621) 9
Your future housing
Where do you want to live?
Area 1: Area 4:
Area 2: Area 5:
Area 3: Area 6:
What typ
es of housing do you want to apply for?
Townhouses
have three or more units next to
each other with one to four bedrooms each, divided
by common walls. These can be single or double
storey and usually have small fenced yards.
Cluster housing
is several separate homes with two
to four bedrooms each, located within a housing
development.
Apartments/flats/units
are usually a complex of
two or more storeys that may be studio style or
have up to three bedrooms. These do not have a
separate yard.
Seniors’ units
are only available to applicants over
55 years of age and are usually in a complex of one
or two storeys with one to two bedrooms.
Detached houses are one house with two or more
bedrooms on its own block of land.
Dual Occupancy
are two detached houses that are on
one block of land, sometimes with a shared driveway.
Duplexes
are usually two units with one to three
bedrooms, each on a block of land, divided by a
common wall. These may be in groups of two to
four.
Do you need disability housing
features for your home? Yes No
If yes, provide details:
Will you accept housing with
shared facilities? Yes No
Does the h
ousehold have pets? Yes No
If yes, provide details:
Additional information you would like to provide?
You may be offered housing from any of the areas listed below.
More than one housing type can be applied for. We will make every effort to offer the type of housing that you have chosen and are eligible for.
However, this cannot be guaranteed. Housing with four or more bedrooms are limited.
Living, bathroom or kitchen facilities may be
shared. If you accept an offer which has
shared facilities, you can choose to remain
listed on the Housing Register for housing
which has its own facilities.
Attach another page if necessary.
Housing Assistance Application
HAA 2.0 (180621) 10
Evidence for your application
What identification evidence can you and other applicants provide?
Primary
Secondary
Australian Birth Certificate or extract Bank, credit or ATM card with your signature
Australian Naturalisation or Citizenship Certificate Bank, credit union or building society statements
Australian Permanent Residency Certificate or stamp Centrelink correspondence with CRN
Immicard, Immigration or sponsorship papers Medicare Card
Temporary Protection Visa or stamp Health Care Card
Australian Passport Seniors/Pensioner Card
Australian Driver licence Taxation Assessment Notice
Photograph identification card
(Queensland Transport) Australian Marriage Certificate
Adult Proof of Age Card
until expiry (Queensland Transport) Australian divorce papers
18+ card
until expiry (Queensland Transport) Life Insurance policies
Keypass Card
Other photographic identification such as
security identification, cash converters card
Queensland Corrective Services verification
Further evidence required
• Decision-making – Public Trustee, Guardian, Power of Attorney documentation
• Income – Centrelink income statements, payslips, employer’s declaration/s
Household members over 16 years receiving Centrelink payments can give consent to the department to obtain income and
assets details electronically from Centrelink.
• Assets – quarterly bank statements and documentation showing details of other assets and their current valuation
• Property ownership – title deed, mortgage documents, contract of sale
• Your need to move – documentation supporting reasons for having to move
• Medical or disability – completed ‘Medical Report’ form (PH068)
• Your wellbeing – completed ‘Support Statement’ form (PH076)
Note: Some income, medical and referral forms are available at www.qld.gov.au/housing. Alternatively, visit your local Housing Service Centre for
forms or advice.
All evidence to support your application must be provided
before an assessment can be completed.
Please tick all that apply.
Below are examples of other types of evidence you and other household members will need to provide, where applicable.
Housing Assistance Application
HAA 2.0 (180621) 11
Declaration and consent
Personal Information Privacy Notice
The Department of Communities, Housing and Digital Economy is collecting personal information on this
form to provide you with housing assistance or assess grant funding applications. This is authorised by the
Housing Act 2003. To assist you with your housing needs and services, relevant personal information may,
in very limited and specific circumstances, be disclosed to: partner agencies, service providers, agencies
authorised by legislative provisions, and local governments and non-governmental agencies that now, or will
provide you with housing and/or support services. Limited personal information may be used for housing
related research, policy or planning functions. Unless authorised or required by law, your personal
information will not be passed on to any other third party without your consent. More information about the
department’s privacy policy is available on our website at www.chde.qld.gov.au.
I understand:
− the instructions given on this form and agree to the Privacy Notice above
− the information on this form will be used by the Department of Communities, Housing and Digital
Economy to register my application for housing assistance, providing I am eligible
− my personal information may be given to government and non-government organisations to provide me
with housing and/or support services
− as the applicant/s, I must advise the department if any circumstances change regarding any household
members listed in and that is relevant to this application
− that I may become ineligible for housing assistance if changes occur to my or my household’s
circumstances, incomes and/or assets
− upon submitting this application, I must provide at least one item from the primary and secondary
identification evidence list above as proof of my identity, one of which, for each applicant, must show a
Queensland address, signature and date of birth.
To the best of my knowledge, the information provided on and in conjunction with this application is true and
correct. I understand that I will commit an offence and be liable to a penalty under the Housing Act 2003 if I
knowingly provide to the Department of Communities, Housing and Digital Economy false or misleading
information that may influence decisions about my eligibility for housing assistance and may make my
application invalid.
Applicant name: Applicant name:
Signed: / / Signed: / /
Date: Date:
I am a Department of Communities, Housing and Digital Economy employee / registered community
housing provider employee / Corrective Services officer / Justice of the Peace / Commissioner for
Declarations / Solicitor.
I have witnessed the above signatures and sighted two of the listed identification evidence items for
each applicant.
Witness name: Position:
Signed: / / Organisation:
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Housing Assistance Application (Department of the Environment and Energy)

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Completed 16 September 2021

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