/ Please complete the application form in full
Applicant Details:
Mr / Mrs / Ms / other / Surname: / First Names(s):
Address:
Postcode:
Contact Telephone No: Home: Work:
E-mail address:
Proof of address: utility bill ▫ Bank statement ▫ Other ▫ Date of Birth
Empty home address that grant is applied for :
Name:
Address:
Postcode: / Do you own the property?
Empty property details:
Property type: flat / mid-terrace / end-terrace / semi-detached / detached / bungalow / maisonette
Property size: 1 bed / 2 bed / 3 bed / 4 bed
No. of bathrooms / WCs: / No. of kitchens:
When was the property built: Pre 1919 / 1919 - 1944 / 1945 – 1979 / Post 1980
What type of heating does the property have?
Length of time property vacant: years months
Why is the property vacant? Please tick all that apply:
Awaiting sale Awaiting planning permission Investment only Disrepair
Other
Do you (alone or jointly with others) own the freehold interest of the property? / Yes  / No 
If jointly owned please give names and addresses of co owners:
MORTGAGE COMPANY (if applicable)
Name:
Address:
Name of contact:
Telephone number:
Mortgage Account Number:
SIGNATURES:
I confirm that I am the legal owner of the above property
Owner 1 signature:
Print name: Date:
Owner 2 signature:
Print name: Date:
Owner 3 signature
Print name: Date
Owner 4 signature
Print name: Date
WARNING: If you knowingly make a false statement you may be liable to prosecution and may be liable torepay any grant monies back to the Council
Tamworth Borough Council is the Data Controller of this information. I declare that to the best of my knowledge the details I have provided are correct. I authorise the Council to carry out any appropriate enquiries to verify the information given in this form and I understand this may involve the disclosure of information protected by the Data Protection Legislation. The information provided by you will be used for the purpose of processing this Grant Application and will not be used for any other purpose.
Signed ______Date: ______

Enclosures

A / Evidence of permanent residential address of applicant
B / Proof of income
C / Proof of ownership of property
D / Consent from co owners (if applicable)
E / Letter from loan company of refusal of finance
F
G

Equality Monitoring

Tamworth Borough Council seeks to become an exemplary council and make sure our services are delivered fairly. We are increasingly aware of the diverse nature of our community and to ensure we are providing services that are accessible for all please take a few minutes of your time to complete this form which will provide us with important information to help us shape delivery of our services.

Tamworth Borough Council gives a commitment that this information will remain confidential and not attributable to any individual.

If you require this information in another format or language please phone 01827 709709 or email .

Ethnic origin

Asian or Asian BritishBlack or Black British Chinese or other ethnic group

□ Indian□ Black Caribbean □ Chinese

□Pakistani□ Black African□ Other mixed, please state….

□ Bangladeshi□ Other Black, please state…

□ Other Asian, please state…..

Mixed HeritageWhite□ Prefer not to say

□ White and Asian□ British

□ White and Black African□ English

□ White and Black Caribbean□ Irish

□ Other Mixed, please state…..□ Scottish

□ Welsh

□ Any other White background, please state….

Disability

Do you consider yourself to have a disability or long term health condition:

□ Yes□ No□ Prefer not to say

Gender

□ Female□ Male□ Prefer not to say

Is your gender identity the same as the gender you were assigned at birth? □ Yes□ No

Sexual orientation

□ Bi-sexual□ Heterosexual□ Gay man□ Gay Woman/Lesbian

□ Other□ Prefer not to say

Religion and Belief

Please tick the box which best describes you

□ Buddhist□ Christian□ Hindu□ Jewish□ Muslim□ Sikh

□ Other religion, please state….. □ No religion □ Prefer not to say

Age

□ Under 16□ 16-24□ 25-34□ 35-44□ 45-54 □ 55-64 □ 65-74 □ 75+ □ Prefer not to say

MAKING EQUALITY REAL IN TAMWORTH