Financial Inclusion Form

• Address of Property
  Address

• Are they a 2 person visit?

  Yes

  No

• Any comments from TMO about tenants

• Planned date of interview

  Date

• Officers Name

  Select Daniel Jones Tracey Reed Jessica Coats Paula Quirke Loraine Pruden Other officer

  • Daniel Jones
  • Tracey Reed
  • Jessica Coats
  • Paula Quirke
  • Loraine Pruden
  • Other officer

• Photo ID

  Media

• Proof of ID shown

• Is the officer satisfied?

  Yes

  No

• Reasoning:

Tenant 1

• Name

• Gender

  Male

  Female

  Other (please specify)

• Ethnicity

  Select White English/Welsh/Scottish/N.Irish/British Any other white background Mixed or multiple ethnic groups Asian or Asian British Black, Black British, African or Carribean Any other ethnic group Prefer not to say

  • White English/Welsh/Scottish/N.Irish/British
  • Any other white background
  • Mixed or multiple ethnic groups
  • Asian or Asian British
  • Black, Black British, African or Carribean
  • Any other ethnic group
  • Prefer not to say

• Date of birth (if not on ID)

Tenant 2

• Name

• Gender

  Male

  Female

  Other (please specify)

• Ethnicity

  Select White English/Welsh/Scottish/N.Irish/British Any other white background Mixed or multiple ethnic groups Asian or Asian British Black, Black British, African or Carribean Any other ethnic group Prefer not to say

  • White English/Welsh/Scottish/N.Irish/British
  • Any other white background
  • Mixed or multiple ethnic groups
  • Asian or Asian British
  • Black, Black British, African or Carribean
  • Any other ethnic group
  • Prefer not to say

• Date of birth (if not on ID)

Other members of household

• Name (s)

• Members to be added (with D.o.b + relationship)

• Members to be taken off

Communications

• 3. Telephone Number

• Telephone Number 2

• 4. Email Address

• Communication preference

  Mobile

  Email

  Letter

• Do they have any communication requirements? i.e large print for vision impairments

  Yes

  No

• Please specify

• Are you generally available during the working week?

  Yes

  No

• When are they not available?

Housing needs

• Does anyone in your household have any physical or mental health conditions or illnesses lasting or expected to last 12 months or more?

  Yes

  No

• Do any of these conditions or illnesses reduce your or their ability to carry out day to day activities or housing situation?

  Yes. a lot

  Yes, a little

  Not at all

  Prefer not to say

• Does anyone in the household have a special housing need because of any of the following:

  Select Permanent physical disability Learning disability Visual impairment Hearing impairment Experiencing domestic abuse Mental health problems Young person leaving care Ex-offender Isolated-no support English is not my first language Issue with alcohol misuse Issue with drug misuse issue with literacy May need help bidding and has no one to help Experiencing anti-social behaviour or harassment Age-related mental infirmity i.e mental health difficulties like Alzheimers/Dementia Age-related physical infirmity i.e arthritis/unsteady Long term mental health condition Long term physical health condition None of the above

  • Permanent physical disability
  • Learning disability
  • Visual impairment
  • Hearing impairment
  • Experiencing domestic abuse
  • Mental health problems
  • Young person leaving care
  • Ex-offender
  • Isolated-no support
  • English is not my first language
  • Issue with alcohol misuse
  • Issue with drug misuse
  • issue with literacy
  • May need help bidding and has no one to help
  • Experiencing anti-social behaviour or harassment
  • Age-related mental infirmity i.e mental health difficulties like Alzheimers/Dementia
  • Age-related physical infirmity i.e arthritis/unsteady
  • Long term mental health condition
  • Long term physical health condition
  • None of the above

• Please specify who and their need.

• Are they working with any support workers/support services

  Yes

  No

• Please specify

Household

• Do they have any pets?

  Yes

  No

• Please specify

• Communal landing area clear of household item? (in flats)

  Yes

  No

  N/A

• Are fittings/fixtures we provide in good condition?

  Yes

  No

  N/A

• Please specify

• Is there any damp or mould in the household? (Provide evidence if possible)

  Yes

  No

• Is the home in a clean and tidy manner and decorated as necessary?

  Good

  Fair

  Poor

  N/A

• Is the garden maintained?

  Good

  Fair

  Poor

  N/A

• Tree Survey – Any Trees larger than House/Flats close to the building?

  Yes

  No

• Any alterations carried out including occupational health adaptations?

  Yes

  No

• Please specify. Has permission been sought?

  Yes

  No

  N/A

• Are there any outstanding repairs which we haven't followed up with?

  Yes

  No

• Please specify

Financial

• Do you claim any Benefits, such as Universal Credit, ESA, Disability Benefits?

  Yes

  No

  N/A

• Is the tenant/s effected by 'Bedroom Tax'?

  Yes

  No

  N/A

• If yes, is the tenant/partner in receipt of DLA/PIP (care medium or high/daily living element) and require overnight care? Or are any of their dependants in receipt of DLA/PIP (care medium or high/daily living element) and require their own bedroom?

  Yes

  No

  N/A

• Are you/your partner in receipt of, or due to claim State Retirement Pension?

  Yes

  No

  N/A

• Have you checked to see if you may qualify for Pension Credit?

  Yes

  No

  N/A

• Do you claim any Discounts/Exemptions/Support in respect of your Council Tax?

  Yes

  No

  N/A

• Do you have debt with your utility providers such as Gas, Electricity, Water etc.

  Yes

  No

  N/A

• Can we pass your contact details on to our Fuel Poverty Officer who may be able to help you further with this?

  Yes

  No

  N/A

• Advise tenants if they are on Universal credit about 'Social Tariffs' that could help them with paying water bills/phones/broadbands

• Ensure they have new contacts list

• Do they know their tenant manager for the area?

• TDC has a number of opportunities for tenants to be involved in the delivery of its housing services – would you be interested in finding out more?

  Yes

  No

  N/A

• What do you think the Council does well as a landlord / what do you think it could improve on?

• Is there anything else the tenant would like to discuss?

• Officers Signature

  Sign

• Tenants Signature

  Sign

• Date of Tenancy check completion

  Date

• What action has been taken from this visit? (Including financial advice/support)