Affordable Rental Office

Affordable Rental Office

Registration to apply for Affordable RentalHousing in the ACT

Use this form to apply for affordable housing assistance in the ACT.

This includes:

• Affordable housing - where the rent payable is less than the full market rent.

Step 1

Complete the form overleaf.

Printneatlyin BLOCKLETTERS.

Make sure you answer all relevant questions; otherwise we may have to return the form to you to be completed.

If you need help with the form, ask an officer from the Affordable Rental Office to help you or call 133 427.

If you need help in a language other than English, complete as much of the form as you can. When you lodge your form, the Affordable Rental Office will contact the Telephone Interpreter Service (TIS) to assist.

Step 2

Complete the accompanying forms if you have been employed in the last 26 weeks you may need your employer to complete the Income Statement from Employer before you lodge this form.

If you receive payments fromCentrelink or the Family Assistance Office, you must provide Prove Of Income.

Step 3

Make sure you have all the required documents.

Please see the ‘Affordable Rental Scheme’ Fact Sheet and theSupporting Documentation Checklist.

Step 4

Lodge your application at Gateway Services or call 6207 1150 or ask a staff member.

Alternatively you can post your completed form and all the required documents to:

Affordable Rental Office

Locked Bag 3000

BelconnenACT 2616

Personaldetails / Applicant1 / Applicant2
1 Title MrMrsMsMissDr / MrMrsMsMissDr
2 Yourfullname / /
3 Date of birth /
//Sex /
//Sex
4 Current Address /

Postcode
5 Postal address /
/

6 Your contact details
Email address / /
7Whatisyourrelationship to theotherapplicant named on this form?
(if applicable) / /
8Are you a permanent resident of Australia? /
Yes
NoAreyoucurrently asponsoredmigrantto
Australia?
NoYes ►Pleaseattach evidence /
Yes
NoAreyoucurrently asponsoredmigrantto
Australia?

NoYes ►Pleaseattach
evidence
9Have you lived in the ACT
for more than six months? /
Yes ►Pleaseattachevidence
No(ifNoyoumaynotbe eligiblefor Affordable Housing Assistance.Pleasespeaktoan Affordable Housing Officerifyouareunsure). /
Yes ►Pleaseattachevidence
No(ifNoyoumaynotbe eligibleforAffordable Housing Assistance. Please speak to an Affordable Housing Officer if youareunsure).
10 Do you have a current application for housing assistance? / No
Yes ►Whatnameistheapplicationin? / No
Yes ►Whatnameistheapplicationin?
11 Thesequestionsareoptional andwillbeusedforstatisticalpurposesonly
AreyouofAboriginal orTorresStrait Islanderorigin?

NoYes-Aboriginal

Yes-BothYes-TorresStraitIslander
12 Do you require an interpreter No
Yes If yes what language

13 Do you speak another language at home other than English?

No, English only Yes, Italian Yes, Greek Yes, Cantonese Yes, Arabic Yes, Vietnamese

Yes, Mandarin Yes, Spanish Yes, If other please specify

14 Providedetailsofsomeonewecancontactifweareunable tocontactyou(EmergencyorThirdpartycontact)

Ifpossible,pleaselistsomeonewholivesin the ACT. Please provide a Name, Address and a contact number

15 IndicateyourHousingrequirements

(Pleaseattachevidence)

Location-seeproperty allocations zonemap

Disabledmodifications

Other

OtherResidents

16 Will any other people live in the property with you permanently (including children)? No Yes ► Givedetailsbelow

Pleaseprovideevidencetoconfirmongoingchildcontactarrangements.

(ie.family courtorders,careandprotectionadvice,separateparental agreement etc.)

Fullname Dateofbirth Relationship IDprovided Contact ProofofContact

No Yes No Yes No Yes

Income / Applicant1 / Applicant2
17 Doyoucurrently No
receiveCentrelinkor Yes ►Pleaseprovide a Centrelink Income
Family AssistanceOfficeStatementfor Housing Authorities
benefits? / No
Yes ►Pleaseprovide aCentrelink Income
Statement for Housing Authorities
18 Areyoucurrently employed? / No
Yes ►Please complete the Income Statement
from Employer on page 9 or provide payslips for the last 26 weeks when lodge this form. / No
Yes ►PleasecompletetheIncomeStatement fromEmployeronpage9orprovide payslipsforthelast26weekswhenlodgethisform.
19 Whatisyourgross income?(iebeforetax)?
Includewagesand pensionpayments / PerweekPerfortnight

$OR$ / PerweekPerfortnight

$OR$
20 Doyoureceiveany otherincome(e.g. overseaspension,interest onbankaccounts,child supportpayments)? / No
Yes ►Howmuchdoyoureceive?
PerweekPerfortnight

$OR$ / No
Yes ►Howmuchdoyoureceive?
PerweekPerfortnight

$OR$
Assets / Applicant 1 / Applicant 2
21 Doyouhaveanybank,No
building societyorcreditYes►Howmanydoyouhave?
unionaccounts?
Pleaseattach thedocuments outlined in
theAffordable HousingFact Sheet – AcceptableFormsofBankStatements / No
Yes►Howmanydoyouhave?
Pleaseattach thedocuments outlined in theAffordable Housing Fact Sheet –
AcceptableFormsofBankStatements
22 Doyouhaveany investments suchas sharesorbonds? / No
Yes►Please attach evidence of your investments / No
Yes►Please attach evidence of your investments
23 Doyouownanycarsor othervehicles,including boats,caravansetc? / No
Yes► Givedetails
Type(e.g. car)Value / No
Yes►Givedetails
Type(e.g. car)Value
24 Doyouownorholdan interestinanyresidential orbusinessproperty
inAustralia? / No
Yes►Givedetails andattach evidenceof ownershipoftheproperty
Nameofowner(s)
Addressoftheproperty / No
Yes►Givedetails andattach evidenceof ownershipoftheproperty
Nameofowner(s)

Addressoftheproperty

25 Doyouhaveanyother assetsnotalreadylisted onthisform?
Donotincludepersonal possessions,furniture, toolsoftradeetc. / No
Yes►Givedetails andattach evidenceofthe valueofeachasset
TypeofassetValue / No
Yes►Givedetails andattach evidenceofthe valueofeachasset
TypeofassetValue
26 Has100pointsbeen providedforeach applicant?
(Pleaseseeattachedchecklist) / Applicant1
No
Yes / Applicant2
No
Yes
Assistancewiththisform
27 Dideitherapplicantreceiveassistance tocompletethisform? / No►GotoDeclarationbyapplicant(s)below?
Yes►Whichapplicantwasassisted?
Applicant1Applicant2
Thepersonwhohelped will needtocomplete the
Declarationat36below
28 Declarationbypersonassistingorcompletingthis form onbehalfoftheapplicants(s) / • Ihavefilledinthisformonthebasis oftheinformation theapplicants(s)providedme.
• Ihavereadouttheformandtheanswerstotheapplicant(s) whoseemedtounderstand them.
• Iunderstandthere arepenaltiesforgivingfalse ormisleadinginformation

Signatureofperson whoassisted

Fullname
Date//

PersonalInformation andPrivacyNotice

Theinformationyouprovidewillbetreatedconfidentiallyandusedto assess your application for affordable housing and for statistical purposes. For these purposes it may be necessary to disclose your information to members of a panel, anybody hearing an appeal in relation to you application, agencies or an organisation with which you have a signed a current ‘Consent to Exchange and ReleaseInformation’ form,aswell as any community housing providers that currently provide you with housing and/or support services, or may do so in future. In addition, we may disclose your information when required or authorised by or under law. You will have access to any information you have provided to ensure that it is still accurate, and you will be allowed to correct it if necessary.

Ifthisformrequiresyoutoincludeinformationaboutothermembersofyour household,youshoulddrawtheirattention, ortheattentionoftheirguardian, tothis noticesothattheyareaware thatinformation aboutthemwillbedisclosedandusedasdescribedabove.

Declarationbyapplicant(s)

Iunderstand:

•TheinstructionsgivenonthisformandnotethePersonalInformation andPrivacyNoticeabove;

•Thisform willbeusedtoregistermyapplication foraffordable housing,providedIameligibleforit;

•ThatImaybecomeineligible foraffordable housing ifchangesoccurtoanyofmy,ormembers ofmyhousehold’s circumstances,and/or incomesand/or assets detailed inthisapplication.

Ideclare:

•Thattheinformationgiveninthisapplicationiscompleteandcorrect;

•ThatIhaveprovidedalloftherequireddocumentsasshownintheDocumentChecklist;

•ThatIhaveshownthePersonalInformation andPrivacyNoticeabovetoanymemberofthehouseholdwhosepersonalinformation isincludedinthisform,or theirguardian.

I acknowledge that a tenancy of a dwelling under the ARO does not entitle applicants 1 or 2 to Social Housing or entitlements under the public rental housing assistance program including eligibility for rental rebate.

28 Declarationbyapplicants(s) Pleasenotethattherearelegal

penaltiesfordeliberatelygivingfalse

ormisleadinginformation.

Declarationbyapplicant(s)

Signatureof

Applicant1

Date//

Signatureof

Applicant2

Date//

Ifyouhavebeenemployedinthelast26weekseither:

•Youremployermustcompletethisform,or

•Youcanprovidepayslipsforthelast26weeks.

Ifyouneedmorethanoneform,contactthe Affordable Rental Office on

133 427 orprintacopyfromthe websiteat

IncomeStatement fromEmployer

6Hastheemployeeworkedanyovertimeinthelast26weeks?

Yes Givethefollowingdetails

1Employee’sname
2Employee’spresentaddress

Postcode
3Nameof employingorganisation

4Whendidtheemployeestart
workwiththeorganisation?//
5What isthegross amountthe employeeearnedinthelast26
weeks(includingovertime,
regularallowancesandpenalties)?

7Employer’sdetails

Name Phone Position Signature

Date//

Companysealorstamp