H O U S E H O L D D E T A I L S continued OTHER HOUSEHOLD MEMBERS Include all dependant children DEPENDANT #3 DEPENDANT #4 DEPENDANT #5 Title: (eg Mr, Mrs, Ms) Surname: First name: Second name(s): Male Male Male Female Female Female Gender: Other: Other: Other: Date of birth: / / / / / / (dd/mm/yyyy) Child Child Child Step child Step child Step child Relationship to Foster child Foster child Foster child applicant: (eg child, Nephew Nephew Nephew grandchild, Niece Niece Niece nephew) Grandchild Grandchild Grandchild Other relationship Other relationship Other relationship Your postal address: (if different from residential address) Your phone and contact details: How do you want Housing SA to contact you?
H O U S E H O L D D E T A I L S continued OTHER HOUSEHOLD MEMBERS Include all dependant children DEPENDANT #3 DEPENDANT #4 DEPENDANT #5 Title: (eg Mr, Mrs, Ms) Surname: First name: Second name(s): Gender: Male Female Other: Male Female Other: Male Female Other: Date of birth: (dd/mm/yyyy) / / / / / / Relationship to applicant: (eg child, grandchild, nephew) Child Step child Foster child Nephew Niece Grandchild Other relationship Child Step child Foster child Nephew Niece Grandchild Other relationship Child Step child Foster child Nephew Niece Grandchild Other relationship Your postal address: (if different from residential address) Your phone and contact details: How do you want Housing SA to contact you?
Private_rental_assistance_application_form-1.docx