Are you in receipt of Yes No Yes No Housing Benefit? Yes No Yes No Do you own or ever owned a property? Yes No Yes No Have you ever failed to keep up payments on any finance or loans? Do you have any County Yes No Yes No Judgements (CCJ’s)? Have you ever been made Yes No Yes No bankrupt? Do you have any rent arrears Yes No Yes No on current or previous properties? Yes No Yes No Have you ever been evicted for rent arrears? Anti-social Behaviour / Criminal Convictions Have you ever been Rent Arrears Rent Arrears evicted from a property Anti-social behaviour Anti-social behaviour for: Noise nuisance Noise nuisance Other Breach of tenancy Other Breach of tenancy Has anyone on the Yes No Yes No application ever been arrested for, cautioned or Please give details and of the Please give details and dates of the offence: offence: convicted of a criminal offence other than a speeding offence? Additional Details for the Failure to disclose full accurate information may affect your application. Accommodation Required How many bedrooms required? Area (we offer 2 area’s please tick) Worthing Felpham What Floor level would you accept Ground, – 1st, 2nd or above 2nd If Yes No above ground level is a lift required? This section to be completed by Worthing Homes Staff Financial Inclusion Affordability Assessment Date of assessment: Name of Assessor:
Are you in receipt of Housing Benefit? Yes No Yes No Do you own or ever owned a property? Yes No Yes No Have you ever failed to keep up payments on any finance or loans? Yes No Yes No Do you have any County Judgements (CCJ’s)? Yes No Yes No Have you ever been made bankrupt? Yes No Yes No Do you have any rent arrears on current or previous properties? Yes No Yes No Have you ever been evicted for rent arrears? Yes No Yes No Anti-social Behaviour / Criminal Convictions Have you ever been evicted from a property for: Rent Arrears Anti-social behaviour Noise nuisance Other Breach of tenancy Rent Arrears Anti-social behaviour Noise nuisance Other Breach of tenancy Has anyone on the application ever been arrested for, cautioned or convicted of a criminal offence other than a speeding offence? Yes No Please give details and of the offence: Yes No Please give details and dates of the offence: Additional Details for the Failure to disclose full accurate information may affect your application. Accommodation Required How many bedrooms required? Area (we offer 2 area’s please tick) Worthing Felpham What Floor level would you accept – Ground, 1st, 2nd or above 2nd If above ground level is a lift required? Yes No This section to be completed by Worthing Homes Staff Financial Inclusion Affordability Assessment Date of assessment: Name of Assessor:
Application-form-Intermediate-rent-and-affordability.docx