H O U S E H O L D D E T A I L S OTHER HOUSEHOLD MEMBERS APPLICANT APPLICANT 2 include all dependant children (YOU) (PARTNER) DEPENDANT #1 DEPENDANT #2 Title: (eg Mr, Mrs, Ms) Surname: First name: Second name(s): Surname: Have you been First name: known by any other names? Second name(s): Male Male Male Male Female Female Female Female Gender: Other: Other: Other: Other: Date of birth: / / / / / / / / (dd/mm/yyyy) Aboriginal and not Aboriginal and not Torres Strait Islander Torres Strait Islander Do you identify as Torres Strait Islander Torres Strait Islander Aboriginal and/ and not Aboriginal and not Aboriginal or Torres Strait Both Both Islander? Neither Neither Not stated Not stated Country of birth: What is your preferred spoken language? Are you under the Yes Yes Guardianship of No No the Minister? Sensory and speech Sensory and speech Physical restriction Physical restriction Do you have a Psychological Psychological disability? Select Intellectual Intellectual all applicable boxes: Health injury, stroke or Health injury, stroke or brain damage brain damage Other disability Other disability Child Child Step child Step child Relationship to Foster child Foster child applicant: (eg child, Nephew Nephew grandchild, Niece Niece nephew) Grandchild Grandchild Other relationship Other relationship
H O U S E H O L D D E T A I L S APPLICANT (YOU) APPLICANT 2 (PARTNER) OTHER HOUSEHOLD MEMBERS include all dependant children DEPENDANT #1 DEPENDANT #2 Title: (eg Mr, Mrs, Ms) Surname: First name: Second name(s): Have you been known by any other names? Surname: First name: Second name(s): Gender: Male Female Other: Male Female Other: Male Female Other: Male Female Other: Date of birth: (dd/mm/yyyy) / / / / / / / / Do you identify as Aboriginal and/ or Torres Strait Islander? Aboriginal and not Torres Strait Islander Torres Strait Islander and not Aboriginal Both Neither Not stated Aboriginal and not Torres Strait Islander Torres Strait Islander and not Aboriginal Both Neither Not stated Country of birth: What is your preferred spoken language? Are you under the Guardianship of the Minister? Yes No Yes No Do you have a disability? Select all applicable boxes: Sensory and speech Physical restriction Psychological Intellectual Health injury, stroke or brain damage Other disability Sensory and speech Physical restriction Psychological Intellectual Health injury, stroke or brain damage Other disability 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
Private_rental_assistance_application_form-1.docx