Medway Council 2013

• Rent account number

• Location
  Address

• Property address

• Rent account balance

• Audit completed on visit number...

  1

  2

  3

• Staff member completing audit

  Select Chris Rourke Adetoun Ajayi Myra Dicken Michael Bull David Crofts Thomas Austin Tracey Barrett Michael Opreshko Sarah Thompson Edina Daddey Vaughan Summerton Lee Georgiou

  • Chris Rourke
  • Adetoun Ajayi
  • Myra Dicken
  • Michael Bull
  • David Crofts
  • Thomas Austin
  • Tracey Barrett
  • Michael Opreshko
  • Sarah Thompson
  • Edina Daddey
  • Vaughan Summerton
  • Lee Georgiou

Tenancy details

• Tenancy start date

  Date

• Tenancy type

  Introductory

  Homeless Licence

  Secure

Tenants details

• Tenants title:

  Select Miss Mrs Ms Mr Dr Rev Sir Lady

  • Miss
  • Mrs
  • Ms
  • Mr
  • Dr
  • Rev
  • Sir
  • Lady

• Please enter tenants full name

• Tenants date of birth

  Date
• Tenants full address
  Address

• Contact details please enter telephone / mobile phone & email

Contact details

• Landline

• Mobile phone

• Email

• Tenants photo ID / Picture

  Media

• Employment / Student status

  Employed

  Self-Employed

  Unemployed

  Student

  Retired

• Does the tenant receive any of the following (please select all)

  Select Income Support / ESA JSA Child Benefit Child Tax Credits Working Tax Credits DLA / PIP Attendance Allowance State Pension Pension Credits Student finance Child Maintenance Other

  • Income Support / ESA
  • JSA
  • Child Benefit
  • Child Tax Credits
  • Working Tax Credits
  • DLA / PIP
  • Attendance Allowance
  • State Pension
  • Pension Credits
  • Student finance
  • Child Maintenance
  • Other

• Please enter other income

• Is this a joint tenancy?

  Yes

  No

• Joint tenants title

  Select Miss Mrs Ms Mr Dr Rev Sir Lady

  • Miss
  • Mrs
  • Ms
  • Mr
  • Dr
  • Rev
  • Sir
  • Lady

• Please enter joint tenants full name

• Joint tenants date of birth

  Date

• Joint tenants contact details (telephone / mobile phone / email etc)

Contact details

• Joint tenants ID / picture

  Media

Household

• Please add each childs details

Child details

• Name

• Gender

  Male

  Female

• Date of birth

  Date

• Relationship to tenant

  Select Son / daughter Grand child Niece / nephew Other Step son Step daughter Parent Aunt / uncle Grand parent

  • Son / daughter
  • Grand child
  • Niece / nephew
  • Other
  • Step son
  • Step daughter
  • Parent
  • Aunt / uncle
  • Grand parent

• Please enter relationship to tenant

• Please add each adults details (other than tenant / joint tenant)

Adult details

• Name

• Gender

  Male

  Female

• Date of birth

  Date

• Relationship to tenant

  Select Son / daughter Grand child Niece / nephew Other Step son Step daughter Parent Aunt / uncle Grand parent

  • Son / daughter
  • Grand child
  • Niece / nephew
  • Other
  • Step son
  • Step daughter
  • Parent
  • Aunt / uncle
  • Grand parent

• Please enter relationship

• Identity / proof of residence

  Media

Pets

• Are there any pets in the household?

  Yes

  No

• Please enter each pets details

Pet

• Species:

• Has the pet been micro-chipped?

  Yes

  No

• Has pet been registered?

  Yes

  No

• Does the pet belong to a household member?

  Yes

  No

• Please give name and address of owner and expected duration of stay

Property details

• Number of bedrooms

  1 Bed

  2 Bed

  3 Bed

  4 Bed

  5 Bed

• Property type

  Select Flat Terraced house Bungalow End of terrace Semi-detached Maisonette Sheltered housing

  • Flat
  • Terraced house
  • Bungalow
  • End of terrace
  • Semi-detached
  • Maisonette
  • Sheltered housing

• Please provide location of W/C

  Upstair

  Downstairs

• Are there any downstairs bedrooms?

  Yes

  No

• Which floor is the flat situated on?

  Ground floor

  First floor

  Second floor

  Third floor

  Fourth floor

• Is the property wheelchair accessable?

  Yes

  No

• Have any adaptations been made to the property in respect of a disability?

  Yes

  No

• Please select as appropriate

  Select Wet-room installed Hand rails fitted inside property Access ramp to main door Stair lift installed Through floor lift installed Ceiling tracking hoist installed Down stairs extention Widened door ways Other

  • Wet-room installed
  • Hand rails fitted inside property
  • Access ramp to main door
  • Stair lift installed
  • Through floor lift installed
  • Ceiling tracking hoist installed
  • Down stairs extention
  • Widened door ways
  • Other

• Please provide details:

• Have there been any structural improvements to the property?

  Yes

  No

• Was approval granted?

  Yes

  No

• Please provide details

• Have you been able to inspect all rooms?

  Yes

  No

• Please provide details of refusal of access:

• Are there any signs of damage to the property?

  Yes

  No

• Please give details of damage:

• Please add image if appropriate

  Media

• Are there repairs needed to the property?

  Yes

  No

• Have the repairs been reported?

  Yes

  No

• Please provide details of repair needed

• Please add image if appropriate

  Media

Hazards

• Are there any combustable materials stored at the property?

  Yes

  No

• Please provide details:

• Please add image if appropriate

  Media

• Is there a smoke alarm at the property?

  Yes

  No

• Is it hard wired?

  Yes

  No

Financial issues

• Does the tenant have any rent arrears?

  Yes

  No

• Has an affordable arrangement been put in place and being adhered to?

  Yes

  No

• Please raise referral to Housing Officer / Welfare Reform Team for affordable repayment plan

• Is the tenant claiming Housing Benefit?

  Yes

  No

• Is the tenant Under / Over occupying the property?

  Under occupied

  Over occupied

  Neither

• Could the tenant satisfy one of the exemptions from size criteria? please select as appropriate

  None

  Over night carer

  Serving soldier

  Child with disability

• Would the tenant like to find a larger property?

  Yes

  No

• Are there any outstanding issues with their HB claim?

  Select Overpayment Suspension Information required Un-notified change of circs

  • Overpayment
  • Suspension
  • Information required
  • Un-notified change of circs

• Please raise referral to Housing Officer / Welfare Reform Team

Support requirements

• Does anyone in the household have a registered disability?

  Yes

  No

• Are they in receipt of disability benefits?

  Yes

  No

• Referrals to be made (please select all)

  Select AP1 CP1 Welfare Reform Team CAB MacMillian WBU Transfer / Mutual exchange Residents association Other Repair Stepchange Caring hands

  • AP1
  • CP1
  • Welfare Reform Team
  • CAB
  • MacMillian WBU
  • Transfer / Mutual exchange
  • Residents association
  • Other
  • Repair
  • Stepchange
  • Caring hands

• Please give details of support required

Welfare Reform

• Have you heard about Welfare Reform?

  Yes

  No

• Are you aware that Universal Credit will be paid into your bank account and be paid monthly in arrears?

  Yes

  No

• Do you currently have a bank account?

  Yes

  No

• Would you be interested in opening a budgeting account if the Council could make one available to you through a local bank or building society?

  Yes

  No

• Have you heard of Credit Unions?

  Yes

  No

  N/A

• Do you use door step lenders or have you ever taken a pay-day loan?

  Yes

  No

  N/A

• How do you access the internet?

  At home

  At work

  Local Library

  At friends / relatives home

  On mobile phone

• How confident are you in researching / locating something "new" on the internet?

  Not at all

  Need some help

  Think I can manage it

  Im sure I can

• Would you be interested in some basic IT training on a:

  Select One to one basis Group training (max 10) From a booklet Internet based learning

  • One to one basis
  • Group training (max 10)
  • From a booklet
  • Internet based learning

Support

• Do you feel that you would benefit from support in the following areas?

  Select Basic ICT Making most of your money Debt Finding employment Claiming benefits

  • Basic ICT
  • Making most of your money
  • Debt
  • Finding employment
  • Claiming benefits

• Referrals to be made

  Select AP1 CP1 Welfare Reform Team CAB MacMillian WBU Transfer / Mutual exchange Residents association Other Repair Stepchange Caring hands

  • AP1
  • CP1
  • Welfare Reform Team
  • CAB
  • MacMillian WBU
  • Transfer / Mutual exchange
  • Residents association
  • Other
  • Repair
  • Stepchange
  • Caring hands

• Please provide details of support provided:

How we contact you

• How should we contact you?

  Select Letters Leaflets Posters Website Meetings Text Phone Email

  • Letters
  • Leaflets
  • Posters
  • Website
  • Meetings
  • Text
  • Phone
  • Email

Declaration

• I declare that the information I have given for the purposes of this form is true and accurate. I understand that giving false information may amount to fraud and I would put my tenancy at risk with the result being that I may loose my home. I may also be subject to criminal prosecution.

• Tenant signature

  Sign