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Mid Sussex
Common Housing Register
APPLICATION FORM
Please ask us if you need help and return your completed form to:
Mid Sussex Homemove
Upton House
7 Perrymount Road
Haywards Heath
West Sussex
RH16 3TN Tel: 0300 333 6715
You should complete this form if you wish to be considered for a home within Mid
Sussex district with one or all of the Common Housing Register partners.
You should also complete the form if you are an existing social housing tenant and
wish to apply for a transfer or register on the mutual exchange scheme.
The form is designed to collect all the information we need to assess your housing
needs.
Please read the form carefully and answer all the questions. We cannot register
your application if the form is not fully completed.
Please enclose any supporting information such as tenancy agreements, notices to
quit, doctors letters etc., with your completed form.
Please note that, when making an application for the housing under part VI of the Housing Act
1996, it is a criminal offence if you knowingly or recklessly give false information in respect of any
matter relating to your application, or withhold information or fail to notify us of any relevant
changes in your circumstances which occur after the housing application has been submitted and
which may affect your eligibility for rehousing.
The Homemove team at Clarion Housing must be notified of changes which may affect your
application as they have responsibility to hold and operate the Common Housing Register. It is
not sufficient to notify other housing associations or the Council of any changes to your
circumstances.
DATA PROTECTION ACT 2018
All information provided on this form and any associate documents will be held on a filing system and
may be used by all of the members of the Common Housing Partnership in carrying out their functions.
This information is subject to the Data Protection Act 2019 and will be treated with confidentiality and
used in accordance with Clarion and Mid Sussex District Council’s registration under the Data Protection
Act 2018.
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MIDSUSSEXCOMMONHOUSINGREGISTERAPPLICATIONFORM
1. YOURHOUSEHOLDDETAILS
Title(Mr/Mrs/Miss/Ms) Applicant Joint Applicant
FirstName/s
Surname/FamilyName
PreviousSurname
(ifapplicable)
DateofBirth
NationalInsuranceNumber
Male/Female Male/Female
Address(Ifyouarehomelesspleasegiveaname,addressandphonenumberwhereyoucanbe
contacted.)
Postcode
HomePhoneNumber
MobilePhoneNumber
WorkPhoneNumber
EmailAddress
RelationshiptoApplicant
OFFICE USE ONLY
Application Number
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Detailsofallotherpeopletobeincludedinyourapplicationforhousing.
Mr,MrsFirstName/s Surname/FamilyNameDateofBirthMale/FemaleRelationship
Miss,Mstoyou
If there is anyone listed above who is part of your application for housing but not living with you
at present, please give details below of their name, address, date of birth and the reason that
you are not living together.
2. YOURELIGIBILITYFORHOUSING
The following information is required in order to assess whether you are eligible for
Housing within the meaning of the Housing Act 1996 (as amended). If you are not eligible
for Housing you will not be offered accommodation.
2.1 Have you or anyone who forms part of your application recently come from abroad -
even if you are a British or European National?
Yes No
2.2 Are you or is anyone who forms part of your application subject to Immigration Control?
Yes No
2.3 If you have answered YES to question(s) 3.1 and/or 3.2, please give full details and the
name(s) of the member(s) of your household who is/are affected.
Ifyouare unclearwhether thisappliesto youplease contacttheCouncil orClarion Housingfor
guidance.We may approach the Home Office to check the information that you have
given and to obtain further relevant information.
2.4 Have you, or any member of your household, lived in a property where an Injunction,
Notice of Possession Proceedings or a Court Order in connection with violence,
harassment, racial harassment or any other anti social behaviour as outlined above has
been served?
PRESENTIMMIGRATIONSTATUS:
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Yes No IfYES,pleasegivedetailsanddatesinthespacebelow:
2.5 Have you, or a member of your household, been convicted of any criminal offence(s) in
connection with violence, harassment, racial harassment, malicious damage, criminal
or immoral behaviour, threatening words or behaviour, neglect or damage to property,
nuisance or annoyance?
Yes No IfYES,pleasegivedetailsanddatesinthespacebelow:
2.6 Are you or someone who lives with you, or who will live with you, currently on the Sex
Offenders Register?
Yes No
Ifyes,pleasegivedetailsanddatesinthespacebelow.
3. ADDITIONALHOUSEHOLDDETAILS
3.1 Is any member of your household pregnant? Yes No
Expecteddateofbirth
PleaseprovideacopyofyourMaternityCerticatewhenyoureceiveit.
3.2 Do you have any pets? Yes No
Pleasegivesdetails(includingbreedifadog)
3.3 Do you have your own transport? Yes No
4. YOURMEDICALCIRCUMSTANCES
You can supply supporting information from your GP, Consultant, Health Visitor or other
Health Professional if you wish. However you do not have to obtain such statements
unless you wish to do so and are prepared to pay any charges arising as a result.
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4.1 Please give the name/s and date/s of birth of your household members whose medical
circumstances are to be considered.
First name(s) Surname/Family Name Date of Birth
4.2 What are your/their illnesses/disabilities? Please describe and say which person/s is /
are affected:
4.3 Is your/their illness/disability?
Worsening Stable Improving Other
Ifotherpleaseexplain:
4.4 What treatment and/or drugs are you/they receiving for the illness/disability? Please
state type and dosage if applicable:
4.5 Is the illness/disability affected by where you live now? Yes No
Ifyespleasegivedetailsofhowyourpresenthousingaffectsyourhealthandsaywhichpersons
areaffected:
4.6 Would the illness/disability be improved by rehousing? Yes No
Ifyespleaseexplainhowandsaywhichperson’shealthwillbeimproved
4.7 Does anyone included in your housing application need a separate bedroom for health
reasons?
YesNo
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Pleasesaywhichpersonneedsaseparatebedroomandexplainwhy:
4.8 Are you all able to enter and leave your home without difficulty?
YesNo
Ifnopleaseexplainwhy:
4.9 Are you all able to use all the rooms and facilities in your home?
YesNo
Ifnopleasesaywhichroom/facilitiesyouareunabletouseandexplainwhy:
4.10 Can you all manage 3 stairs?
YesNo
4.11 Is anyone confined to a wheelchair?
YesNo
4.12 Does anyone occasionally use a wheelchair?
YesNo
4.13 Does anyone receive any benefits because of their illness/disability?
YesNo
Ifyespleaselistwhichbenets:
4.14 If you have a carer does the carer receive any benefits for looking after you?
YesNo
Ifyespleaselistwhichbenets:
4.15 Does your home have any adaptations (special fittings to help you live independently in
your own home)?
YesNo
Ifyespleasesaywhatadaptationshavebeenmade,e.g.StairLift,Ramp,HandRails,Shower
etc
4.16 If you are rehoused would you require any adaptations to your new home?
YesNo
Ifyes,whattypee.g.StairLift,Ramp,HandRails,Showeretc
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4.17 Could adaptations to your present home help solve your housing problem?
YesNo
Ifyeswhatsortofadaptions?
FormoreadviceonadaptationsyoushouldcontacttheHousingStandardsTeamofMidSussex
DistrictCouncil,Telephone01444477292,whoadministertheDisabledFacilitiesGrantsscheme
forwhichyoumaybeeligible.Bothtenantsandowneroccupierscanapplyforthesegrants.For
furtheradviceyoucanalsocontact‘AnchorStayingPut-MidSussex’whorunaschemetohelp
olderand disabledpeopletoremainindependent intheirownhomes.If youare atenant ofa
housingassociationyourlandlordmayconsiderundertakingthenecessaryadaptationstoyour
property.Inthissituationyoushouldcontactyourlandlordinitiallyforguidance.
AnchorStayingPut-MidSussexandCrawleycanbecontactedbytelephoning01444415475or
byemailingmidsussexandcrawley@anchor.org.uk.
4.18 Please give the name and address of your GP
5. HOUSINGSUPPORT
Wemaybeabletoarrangethesupportyouneedwhenyouarerehoused,solongasthereisa
suitableserviceavailable.
By‘support’wemeanhelpmanagingyourmoneyandrunningyourhome,dealingwithpaperwork
andaccessingtheotherservicesyoumayneed.
Therearetwotypesofhousingsupport:
•Supportgivenataspecialisedhousingschemetoeveryonewholivesthere,forexamplein
ExtraCareHousingforfrailolderpeopleorspecicsupportedhousingschemesforyoung
peopleorpeoplewithlearningdisabilities.
•‘Floating’or‘Outreach’supportthatcomestoyouwhereveryoulive.
5.1 Do you or your household need housing with support?
Yes No
IfNo,pleasegotoQuestion7.
5.2 What type of housing support do you or your household need to help manage? (Tick all
that apply)
Managingyourmoneyandbudgeting AnEmergencyalarmsystem
Accessingcommunityservices Personalcare
Managingtenancyresponsibilities Helpwithpaperwork
Obtaininghealthcare Other(pleasespecify)
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6.
5.3 Are you currently getting any care and support to help you manage?
YesNo
IfYes,pleasedescribethesupportthatyoureceiveatthemoment.
5.4 Who provides the help? (Tick all that apply)
Family/friends/neighbours SocialandCaringServices
VoluntaryAgency Other(pleasespecify)
5.5 Do you regularly need help during the night?Yes No
5.6 Please tick all of the following support arrangements that would suit your needs:
Ordinaryhousingwithsupportprovidedbyvisitingstaff
Self-containedhousinginaspecialisedschemewheresupportisprovidedtoeveryone
wholivesthere
Aspecialisedsharedhousewheresupportisprovidedtoeveryonewholivesthere
Specialisedsupportedhousingwithstaffonsiteproviding24hourcareandsupport.
5.7 If you are an older person, which of these options would suit your needs:
ShelteredHousingforolderpeoplewithsupportfromonsiteorvisitingstaff
ExtraCareHousingforolderpeoplewithadegreeoffrailtyordisabilitywhoneed
personalcare
5.8 A variety of support options can be provided to people with different types of need. To
help us assess what would suit you please tick any of the following difficulties that you
have:
Alearningdisability Hearingdifculties
Aphysicaldisability Sightimpairment
HIV/AIDS Aproblemwithalcohol
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Aproblemwith
drugsA
terminalillness
Anacquiredbraininjury Other(pleasespecify)
Amentalhealthneed
5.9 Please tick any of the descriptions that apply to you
Anolderperson(60+) Partofahomelesshousehold
Anex-offender Singleandhomeless
Fleeingdomesticviolence/abuse Aroughsleeper
Homelessaged16-17 Agypsyortraveller
Acareleaver Arefugee
Ateenageparent
Ifnoneoftheaboveapplytoyoubutyoustillneedsupportpleaseusethespacebelowtotellus
aboutyourneeds:
5.10 Sharing Information about your support needs with others
Wemayneedtodiscussyoursupportneedswithotherrelevantorganisations. Wewillalsoneed
topassondetailsaboutyoursupportneedstootherorganisationswhoprovidesupport.Sothat
wecanpassondetailsofyoursupportneedstoothers,weneedyoutoagreethatwecandothis.
Pleasereadcarefullybeforeyouagree.Ifyoudonotunderstandwhatyouareagreeingto,please
ask.
I authorise Mid Sussex District Council and the Common Housing Register Team at
Affinity Sutton to convey essential and relevant information in relation to my support
needs to Support Providers, Supporting People, Health Services and WSCC Social &
Caring Services.
I understand that this information may be used when assessing my support needs and
suitability for allocation of support services.
Signature of Applicant
Date
I confirm that I, the Joint Applicant, understand and agree to the above
Signature of Joint Applicant
Date
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6. YOURCURRENTACCOMMODATION
6.1 Please indicate which of the following best describes your current accommodation:
Housingassociationtenant HMForces
LocalAuthority/Counciltenant Hospital
Privatetenant Women’sRefuge
Homeless(Noxedabode) Bed&Breakfast
Prison Intemporaryaccommodationarranged
bytheCouncilfollowinga
Incare,inaccommodationarranged homelessnessapplication
bySocialServices
Lodgingswithresidentlandlord SharedOwnership
Livingwithrelatives Owneroccupier
Livingwithfriends Other
Accommodationtiedtoemployment Pleasegivedetails
Rent(Agriculture)Acttenancy
6.2 Do you occupy accommodation that is, or ever has been, provided for someone in your
family because they are or were a farmworker?
Applicant Yes No
JointApplicant Yes No
6.3 DO YOU OWN ANY PROPERTY?
6.3.1 Are you buying or do you own the freehold or leasehold, or have any legal interest in the
property that you occupy? (If you are married you will have a legal interest in the marital
home owned by your husband or wife.)
Applicant Yes No
JointApplicant Yes No
IfyouhaveansweredYESabove,pleasestatebelowtheproperty’sapproximatevalueandthe
amountofanyoutstandingmortgageorloans.
Approximatevalue Amountofanyoutstandingmortgagesandloans
*Youwillneedtosupplyanestateagent’svaluationanddetailsofyouroutstandingmortgage
fromyourbank/buildingsocietyorbysolicitor’sletter.
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IfyouhaveansweredYESabove,pleaseexplainwhyyouneedalternativeaccommodation.
6.3.2 Are you buying or do you own the freehold or leasehold, or have any legal interest in any
other residential property that you do not currently occupy? (If you are married you may
have a legal interest in your former marital home occupied by your husband or wife.)
Applicant Yes No
JointApplicant Yes No
IfYES,pleasegivedetailsincludingtheaddressandexplainwhyyoudonotoccupytheproperty.
6.4 Are you or is your husband or wife, the tenant or joint tenant of a property that you do
not occupy? (If you are married you will have the right to occupy a property where your
husband or wife is the tenant)
Applicant Yes No Sole/Jointtenant
JointApplicant Yes No Sole/Jointtenant
IfYES,pleasegivedetailsoftheaddressandthelandlordandexplainwhyyoudonotlivethere.
6.5 Please indicate the type of property that you currently occupy.
House Caravan/MobileHome
Flat Bedsit/StudioFlat
Bungalow Other(pleasegivedetails)
Maisonette
6.6 Please give details of your:
Weekly/MonthlyRent
and/orMonthlyMortgage
and/orWeekly/MonthlyServiceCharge
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6.7 Please complete the details requested below. For example, if you have three bedrooms
you should tick three of the bedroom boxes even if you do not use all of them. YOU
MUST COMPLETE THIS QUESTION IN ORDER FOR US TO ASSESS YOUR HOUSING NEED.
RoomsPleasetickaOnwhichooristheroomWhousestherooms?Pleasetickifthe
boxforeachsituated?e.g.basement, roomislessthan
oftheroomsground,rstetc.5squaremetres
intheproperty (i.e.2.24mx
2.24m/7.25ftor
less)
Bedsit/
StudioFlat
Bedroom1
Bedroom2
Bedroom3
Bedroom4
LivingRoom
DiningRoom
Kitchen
Bathroom
SeparateWC
Other
Ifotherplease
givedetails
6.8 Please give details of anyone living with you who is NOT INCLUDED in your housing
application.
Firstname(s) Surname/FamilyName Relationshiptoyou
6.9 What floor/s is your accommodation on?
Ground/1st/2nd/other
Istherealift? Yes No
Page13
6.10 Do you have use of:
Cookingfacilities? Yes No
Hotwater? Yes No
Aninside
WC?YesNo
Bathroomfacilities? Yes No
Ashoweronly? Yes No
Centralheating? Yes No
Ifnot,whatheatingisprovided?
Agarden? Yes No
Ifyes,isitshared? YesNo
6.11 If your home is affected by any of the conditions listed below, a report from the
Environmental Health Department may be needed. Please tick ANY of the following if
they SEVERELY affect your current home.
Leaking
roofDamp
Rottingwood Faultyelectricalwiring
Structuraldisrepair
Haveyoureportedtheproblemtothe
EnvironmentalHealthDepartment
oftheCouncil? Yes No
Pleasegivedetailsoftheserepairproblems
Page14
7. YOURPASTANDPRESENTHOUSING
Please list ALL the addresses where you and your joint applicant (if any) have lived in the
past 5 years. You must complete this section in full for your application to be registered.
You should start with details of where you live now.Pleasecontinueonaseparatesheetif
youneedto.
7.1 Applicant
Fulladdress Name&address Date Date Typeof Reasonfor
oflandlord livedfrom livedto occupancy leaving
7.2 Joint Applicant
Currentaddress
Previousaddress
Previousaddress
Previousaddress
Currentaddress
Previousaddress
Previousaddress
Previousaddress
Council/PrivateRent
HsingAssoc/Owner
Friends/Family/Other
Council/PrivateRent
HsingAssoc/Owner
Friends/Family/Other
Council/PrivateRent
HsingAssoc/Owner
Friends/Family/Other
Council/PrivateRent
HsingAssoc/Owner
Friends/Family/Other
Council/PrivateRent
HsingAssoc/Owner
Friends/Family/Other
Council/PrivateRent
HsingAssoc/Owner
Friends/Family/Other
Council/PrivateRent
HsingAssoc/Owner
Friends/Family/Other
Council/PrivateRent
HsingAssoc/Owner
Friends/Family/Other
Page15
Family
Friends
Housing Association
Owner
Private Rent
Other
Family
Friends
Housing Association
Owner
Private Rent
Other
Family
Friends
Housing Assoc
Owner
Private Rent
Other
Family
Friends
Housing Association
Owner
Private Rent
Other
Family
Friends
Housing Association
Owner
Private Rent
Other
Family
Friends
Housing Association
Owner
Private Rent
Other
Family
Friends
Housing Association
Owner
Private Rent
Other
Family
Friends
Housing Association
Owner
Private Rent
Other
8. YOUREMPLOYMENT/INCOME/FINANCIALDETAILS
8.1 Are you employed? Applicant Joint Applicant
YesNoYesNo
Permanent Permanent
Temporary Temporary
Casual Casual
JobTitle
Occupation
Name,addressandtelephone
numberofemployer
Whereisyourjobbased?
8.2 Please indicate your gross annual household income before tax and other deductions.
8.3 Please give details of any Benefit/Tax Credits/Pensions your household receives.
Nameofbenet Amountreceived
8.4 Please give details of any other income e.g. from capital investments, maintenance
payments or payments through the Child Support Agency.
8.5 What is the value of any savings
or investments that you have? Applicant Joint Applicant
8.6 Do you or your Joint Applicant have any personal debt? Yes No
Pleasestatetheamountofyourpersonaldebt(excludingyourmortgage).
weekly/fourweekly
weekly/fourweekly
weekly/fourweekly
weekly/fourweekly
Page16
9. THEREASONFORYOURAPPLICATION
9.1 Please tick any of the following boxes if they apply to you.
Accommodationtoosmall Homeless(noxedabode,rooess)
Accommodationtoolarge Marital/relationshipbreakdown
Needforindependence Domesticviolence
Haveyoureportedthistoyourlandlord?
YesNo
Servedwithnoticetoquit/
seekingpossession Harassment
Haveyoureportedthistoyourlandlord?
YesNo
Askedtoleavewithinfourweeks
Racialharassment
Lossofaccommodationtiedto Haveyoureportedthistoyourlandlord?
employment Yes No
Cannotaffordpresent Neighbourproblem
accommodation Haveyoureportedthistoyourlandlord?
YesNo
Needretirementaccommodation
Readytoleavesupportedhousing Leavingarmedforces
Needhousingwithsupport Leavinghospital
Tobeclosertowork,hospital,relatives, Leavingprison
amenities,shops
Presentaccommodationunsuitablefor Other(pleasegivedetailsonsection16)
medicalreasons
9.3 If you are homeless or threatened with homelessness have you approached your local
Council for help?
Yes No IfYes,whichcouncil?
IfYes,when?
9.4 If you have ticked more than one box what is the main reason for your application?
It is important that any additional relevant information is provided in the space below. Please
continue in Section 17. Such information will help us to make a proper assessment of your
application.Youshouldsupplycopiesofanynoticesthatyouhavereceivedandanyotherrelevant
paperworkinsupportofyourapplication.
Page17
10. YOURHOUSINGREQUIREMENTS
10.1 How many bedrooms do you need?
Normally,extrabedroomscanonlybeconsiderediftherearestrongmedicalreasonsforsuch
requirements.
10.2 Please tick the type or types of accommodation you would accept.
Selfcontained Flat Maisonette Bungalow House Sheltered/
studioat retirementor
  supported
10.3 Please tick those facilities which are ESSENTIAL to you.
Retirementaccommodation Levelaccessshower
Groundoorproperty Closetoamenities
Liftifabovegroundoor Supportedhousing
Indicatehighestooryouwouldaccept Garden
withlift(e.g.Grd,1st,2nd,3rd)
Petsallowed
Wheelchairaccess
Other,
Centralheating pleasespecify
10.4 Please tick if you wish to be considered for any of the following:
MutualExchange(existinglocalauthorityorhousingassociationtenantsonly).Ifyou
wishtobeconsideredforaMutualExchangeyourcontactdetailsandproperty
requirementswillbepublishedonHomeSwapperatwww.homeswapper.co.uk
SharedOwnership(i.e.partrent,partbuy)/HomeBuySchemeorotherLowCost
Homeownershipschemes.
IntermediateRentSchemes(IntermediateRentisbetweenanaffordablerentanda
marketrent)
You should also register with Moat at www.moathomes.co.uk/county/sussex
11. YOURPREFERREDAREAS
11.1 Are you willing to be considered for accommodation anywhere in the Mid Sussex
district? (see map on last page of form)
Yes No Whattownorvillageisyour1stchoice?
IfyouhaveindicatedNOabove,pleasetickanyoftheareasortownsorvillageswhereyouwish
tobeconsideredforaccommodation.
Page18
ALL Northern area ALL Central area ALL Southern area
Ardingly Ansty Albourne
Ashurstwood Balcombe BurgessHill
Copthorne Bolney Fulking
CrawleyDown Cuckeld Hassocks
EastGrinstead HaywardsHeath Hurstpierpoint
Handcross Lindeld Poynings
HorstedKeynes ScaynesHill Pyecombe
PeasePottage Stapleeld SayersCommon
Sharpthorne Twineham
TurnersHill Warninglid
WestHoathly
11.2 If you want to move to a particular area in order to give or receive support e.g. from/to
a relative please give details
11.3 If there is anywhere, for example a part of a town or village, that you do not want to
be considered for because you have a personal reason for not wanting that area (e.g.
history of previous harassment) please give details
11.4 If you wish to be considered for housing in areas outside Mid Sussex you can now apply
direct to the council that covers the area you want to live in.
12. YOURFAMILYCONNECTIONWITHINMIDSUSSEX
Doyouoryourjointapplicanthave
•aparent
•anadultchildor
•abrotherorsister
whohavebeenlivingintheMidSussexDistrict(seemap)formorethan5years?
Yes No
N.B We may need to make enquiries to confirm this information. Applicants with a local connection
with Mid Sussex are awarded additional priority under the Council’s Allocation Scheme.
Priority may also be given when allocating first lettings of new housing
developments in towns and villages to applicants with a connection to that town or village.
Page19
IfyouhaveansweredYESabove,pleasegivedetailsofallrelativesbelow.(Ifmorethanoneclose
relativelivesatthesameaddress,pleaselistthemtogether)
Name of relative(s)
Relationshiptoyou
Addressesoverlast DatefromDateto
5years
Name of relative(s)
Relationshiptoyou
AddressesoverlastDatefromDateto
5years
Name of relative(s)
Relationshiptoyou
 DatefromDateto
Addressesoverlast
5years
Pleasecontinueonseparatesheetifnecessary
currentaddress
previousaddress
previousaddress
currentaddress
previousaddress
previousaddress
currentaddress
previousaddress
previousaddress
Page20
13. YOURRENTHISTORY
14.1 Do you owe any housing related charges or rent to the Council, another council or a
Housing Association?
Yes No IfYES,pleasegivedetailsinthespacebelow:
14. CHANGESINYOURCIRCUMSTANCES
It is essential, in order to maintain your position on the Housing Register, that you notify
the Homemove Team at Clarion Housing of ANY changes to your circumstances as soon
as they occur. Do not wait until it is time to renew your application to tell us about changes
to your circumstances.
15. RENEWALOFYOURAPPLICATION
The Homemove Team at Clarion Housing may send you a form to complete to renew your
application. If you do not return the form, completed, your name will.be removed from the
Housing Register.
16. PLEASEUSETHISSPACETOGIVEUSANYFURTHERINFORMATIONYOUWISHUSTO
CONSIDER
Page21
17. DECLARATION
Pleasereadthedeclarationbelowandsignunderneath.
AreyouoryourpartnerrelatedtoanyCouncillororCommitteememberoremployeeworkingfor
anyofthepartnerorganisationsinvolvedwiththeMidSussexCommonHousingRegister?
Yes No
IfYES,pleasestatethenameofthepersonandtheirrelationshiptoyou.
Name
Relationship
Whodotheycurrentlyworkfor/represent?
Inwhatposition?
Iunderstandthatthisapplicationforhousingdoesnotcompriseanofferorpartofanofferof
accommodation, and does not bind the organisations involved with the Mid Sussex Common
HousingRegisterinanyway.
TheinformationIhavegivenonthisformistothebestofmyknowledgeandbelief,accurate.I
undertaketoinformClarion Housingifmycircumstanceschangeaftercompletingthisform.
IauthoriseClarion Housing,MidSussexDistrictCouncilandallthepartnerorganisationsinvolved
withtheMidSussexCommonHousingRegistertomakesuchenquiriesintomyapplicationasmay
benecessary(includingcontactingmyGPoranyotherHealthProfessional).
I also authoriseClarion Housing, Mid Sussex District Council and all the partner organisations
involvedto conveyany essentialand relevantinformation inrelationto myhousing application
tootherpartnerorganisationstotheMidSussexCommonHousingRegister,
andtootherstatutoryagencies.
Iunderstandthatanyfalse or
misleadinginformationgiveninrelationtothisapplication which
leadstoapropertybeingallocatedtomemayresultinevictionproceedingsbeingtakenagainst
meandthatImaybeprosecuted.
SignatureofApplicant Date
SignatureofJointApplicant Date
Ifyouwouldliketogivepermissionforustodiscussthedetailsofyourapplicationwithanyone
elsepleasecompletethesectionbelow:
Name: Relationshiptoapplicant:
Address:
TelephoneNumber:
Page22
18. EQUALOPPORTUNITIES
It is against the law for the Council and housing associations to discriminate against anyone
applyingforhousing.
ToensurethattheCouncilandhousingassociationswhoworkwiththeCouncildonotdiscriminate
againstanyonebecauseoftheirages,race,religion,ethnicgroup,gender,sexualorientationor
disability,weneedtocollectinformationabouteveryonewhoappliesforhousing.
Theinformationcollectedinthissectiondoesnotformpartofyourapplicationandwillonlybe
usedformonitoringpurposes.
18.1 What gender is the Main Applicant?
Prefernottosay Male Female Transgender
18.2 Which age category does the Main Applicant belong to?
16-24  25-44  45-59  60-64 65-74 75+
18.3 Does any member of your household have any long-term illness, health problem or
disability?
Yes No
IfYES,doesthisillnessordisabilitylimittheiractivitiesinanyway?
Yes No
18.4 Please describe your household’s ethnic group or background:
Prefernottosay
A - White
English/Welsh/Scottish/ GypsyorIrishTraveller
NorthernIrish/British
Anyotherwhitebackground
Irish
B - Mixed / multiple ethnic groups
WhiteandBlackCaribbean WhiteandBlackAfrican
WhiteandAsian AnyotherMixed/multiple
ethnicgroupbackground
C - Asian / Asian British
Indian Pakistani
Bangladeshi Chinese
AnyotherAsianbackground
Page23
D - Black / African / Caribbean / Black British
African
Caribbean
AnyotherBlack/African/Caribbean
background
E - Other ethnic group
Arab
Anyotherethnicgroup
18.5 Please provide more information as to which ethnic group you belong to
Prefernottosay
EasternEuropeancountry,
pleasespecify:
OtherEuropeancountry,pleasespecify:
Other,pleasespecify:
19. SUPPORTINGDOCUMENTATION
You need to send us the following evidence to support your application. Please tick all
the information that you are sending:
Allinformationyousendshouldbeclearlymarkedwithyournameandaddressasitappearson
theapplication.Photocopiesofdocumentsareacceptable.
Pleasesend/orbringinCOPIESto:
Mid Sussex Homemove
Upton House, 7 Perrymount Road, Haywards Heath, West Sussex, RH16 3TN
Tel: 0300 333 6715 Email: mid.sussexhomemove@clarionhg.com
19.1 Proof of identity (for each member of the household) UNLESS you are an existing tenant
of Affinity Sutton and you have already provided these documents:
PassportOR
BirthcerticateANDphotographicidenticatione.g.Drivinglicence,employeeI.D.card
orrailcard
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19.2 Proof of residency (for both applicants if this is a joint application). (e.g. utility bill,
bank statement, etc). One proof of residency required for your current address
AND one proof of residency from 6 months ago UNLESS you are an existing
tenant of Affinity Sutton and have already provided these documents.
19.3 Other proof, where relevant
a) Households with children (for each child):
ChildbenetorChildTaxCreditdocumentsshowingaddressandchildren’snamesand
datesofbirthe.g.directpaymenttobankaccountshowingnamesanddatesofbirths
ofchildren.
Bankaccountstatement(ifover16yearsofage)
b) Households with access rights to children (for each child):
Residencyorder
Letterfromresidentparent
Solicitor’sletter
c) Applicants that are not citizens of EEA
Passportand/ortraveldocumentsissuedbyUKBorderAgency
d) EEA citizens, including UK citizens returning to the UK or coming for the first time:
Passportandevidenceofemployment
e) EEA citizens from A8 countries
PassportandevidenceofemploymentplusproofofregistrationwithHomeOfce
f) Tenants UNLESS you are an existing tenant of Affinity Sutton
Tenancyagreement
g) Owner-occupier (current or previous)
EstateAgent’svaluationandmostrecentmortgagestatementor,ifpropertysold,
CompletionStatement
h) Living with family / friends:
Letterfromhouseholder
i) Pregnant:
MATB1OR
MaternitynotesOR
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Letterfrommidwife/doctor
j) Income:
Evidenceofincomesuchaspayslips(4mostrecent),pension/benetbooksor
documents,etc.
k) Savings:
Bank/buildingsocietystatements(last6months),sharecerticatesorotherrelevant
evidenceofinvestments
l) Exceptional circumstances:
Relevantevidencefromofcialsourcessuchaspolice,housingofcer,socialworker
ordoctor
20. COMPLETEDFORM
Thank you for completing your application to join the Mid Sussex Common Housing
Register. Please send your form to:
The Common Housing Register Team
Affinity Sutton, Norris House, Burrell Road, Haywards Heath, West Sussex, RH16 1YL
We will be in contact with you shortly to advise whether or not your application has been
registered. If you have any queries please contact the Common Housing Register Team.
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Mid Sussex Homemove,
Upton House, 7 Perrymount Road, Haywards Heath, West Sussex RH16 3TN
AMAPOFTHEMIDSUSSEXDISTRICT
HG-019-01-10 March2010
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