"Application Form for Transitional Housing" - Western Australia, Australia

This printable "Application Form for Transitional Housing" is a document issued by the Western Australia Department of Regional Development specifically for Western Australia residents.

Download a PDF of the latest edition of the form down below or find it through the department's forms library.

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OPENING DOORS
Department of Regional Development
To A ordable Housing
Housing Authority
GOVERNMENT OF
WESTERN AUSTRALIA
APPLICATION FORM FOR TRANSITIONAL HOUSING
Please answer the following questions by typing in the form or printing the form and writing your responses.
See Part 8 for details on how to submit the form.
Please check one of the following:
Application for Transitional Housing in:
Broome
Derby
Halls Creek
Kununurra
PART 1 – APPLICANT INFORMATION
PART 1.1 INFORMATION ABOUT APPLICANT
Mr
Mrs
Miss
Ms
Other
Family Name
Given Names
Male
Female
Intersex*
*Applicants who do not identify themselves as male or female
Date of Birth
(dd/mm/yyyy)
Phone
Mobile
Email
Address
State
Postcode
Passport Number
Driver’s License Number
Country of Issue
State
How did you hear about the Transitional Housing Program?
Housing Authority Website
Newspaper
Radio
Word of Mouth
Social Media (Facebook/Twitter/Other)
Community
Organisation Referral
PART 1.2 ALTERNATE CONTACT PERSON
Family Name
Given Names
Date of Birth
(dd/mm/yyyy)
Phone
Mobile
Email
OPENING DOORS
Department of Regional Development
To A ordable Housing
Housing Authority
GOVERNMENT OF
WESTERN AUSTRALIA
APPLICATION FORM FOR TRANSITIONAL HOUSING
Please answer the following questions by typing in the form or printing the form and writing your responses.
See Part 8 for details on how to submit the form.
Please check one of the following:
Application for Transitional Housing in:
Broome
Derby
Halls Creek
Kununurra
PART 1 – APPLICANT INFORMATION
PART 1.1 INFORMATION ABOUT APPLICANT
Mr
Mrs
Miss
Ms
Other
Family Name
Given Names
Male
Female
Intersex*
*Applicants who do not identify themselves as male or female
Date of Birth
(dd/mm/yyyy)
Phone
Mobile
Email
Address
State
Postcode
Passport Number
Driver’s License Number
Country of Issue
State
How did you hear about the Transitional Housing Program?
Housing Authority Website
Newspaper
Radio
Word of Mouth
Social Media (Facebook/Twitter/Other)
Community
Organisation Referral
PART 1.2 ALTERNATE CONTACT PERSON
Family Name
Given Names
Date of Birth
(dd/mm/yyyy)
Phone
Mobile
Email
PART 1.3 YOUR HOUSING SITUATION NOW
What is your current living arrangement?
Housing Authority (public housing)
Community Housing
Homeless
Crisis Accommodation
Living with friend or relative
Other
Years and months at current address Years
_____
Months
_____
Are you currently on the Housing Authority’s Waitlist?
Yes
No
Previous Address (please include state and postcode)
Were you renting?
Yes
No
If renting, what were you paying per week? $
Were you living with friends or family?
Yes
No
None of the above
If you are living in public housing (Housing Authority) is the Tenancy Agreement in your name? If you are not in public
housing, please ignore this question.
Yes
No
PART 1.4 HOUSING REFERENCE
If you were renting, please provide the name and phone number of a previous landlord.
Name
Phone
Email
Address of rental property
PART 2 – HOUSEHOLD DETAILS
PART 2.1 APPLICANT
Family Name
Given Names
Date of Birth
Gender M/F/I
Marital Status
Aboriginality
1
Male
Single
Yes
Female
Married
No
(dd/mm/yyyy)
Intersex
Partner/De Facto
PART 2.2 OTHER HOUSEHOLD MEMBERS
Other household members include partner, dependants such as children, non-dependants and carers
Family Name
Given Names
Date of Birth
Gender M/F/I
Relationship to Applicant Aboriginality
2
Male
Yes
Female
(dd/mm/yyyy)
No
Intersex
3
Male
Yes
Female
(dd/mm/yyyy)
No
Intersex
4
Male
Yes
Female
(dd/mm/yyyy)
No
Intersex
5
Male
Yes
Female
(dd/mm/yyyy)
No
Intersex
6
Male
Yes
Female
(dd/mm/yyyy)
No
Intersex
PART 2.3 CHILDREN’S SCHOOL DETAILS
Family Name
Given Names
School Name
School Address
School Year (K - 12)
1
2
3
4
5
6
PART 3 – EMPLOYMENT / TRAINING
PART 3.1 EMPLOYMENT / TRAINING STATUS
Employed (fill out parts 3.1a and 3.1b)
Training (fill out part 3.1c)
Soon to be employed
Soon to be in training
Student
None
3.1a Employment Information
Occupation
Length of Employment
Years
_____
Months
_____
Business/Employer Name
Contact Person/Referee (Manager/Payroll Officer)
Address
Phone/Mobile
Email
3.1b Previous Employment Information
Business/Employer Name
Length of Employment
Years
_____
Months
_____
3.1c Training Information
Full time
Part Time
Name of College/Institution
Length of Training Qualification
Years
_____
Months
_____
Completion Date of Training Qualification
(dd/mm/yyyy)
Contact Name
Phone/Mobile
PART 3.2 EMPLOYMENT / TRAINING STATUS OF OTHER HOUSEHOLD MEMBERS
Employed (fill out parts 3.2a and 3.2b)
Training (fill out part 3.2c)
Soon to be employed
Soon to be in training
Student
None
3.2a Employment Information
Occupation
Length of Employment
Years
_____
Months
_____
Business/Employer Name
Contact Person/Referee
Address
Phone/Mobile
Email
3.2b Previous Employment Information
Business/Employer Name
Length of Employment
Years
_____
Months
_____
3.2c Training Information
Full time
Part Time
Name of College/Institution
Length of Training Qualification
Years
_____
Months
_____
Completion Date of Training Qualification
(dd/mm/yyyy)
Contact Name
Phone/Mobile
PART 4 – FINANCES
PART 4.1 APPLICANT INCOME AND ASSETS
If the amount is nil write ‘Nil’ . If the amount is an estimate write ‘E’ before the amount.
4.1a Salary or wages
Are you self-employed?
Yes
No
What is your total average gross weekly salary (before tax)?
4.1b Gross Investment Income (E.g. Rental property, shares, etc)
Income Type
Paid By
Average Weekly Total
4.1c Income from Business / Partnership / Company / Trust
Business Name
Business Type
Average Weekly Total
4.1d Government Benefits (E.g. Centrelink, pension)
Benefit Type
Average Gross Weekly Total
4.1e Child Support Payments (maintenance payments for child, not Centrelink payments)
Paid By
For the Benefit of
Amount Paid
Amount Received
4.1f Other Income
Paid by
Income Type
Average Weekly Total
PART 4.2 OTHER HOUSEHOLD INCOME EARNERS
Name
Age
Relationship to you
Average weekly total
PART 4.3 DEBT (if relevant)
4.3a Loans
Name of Lender
Full name of borrowers
Amount owed
4.3b Credit Cards / Charge Cards
Card Provider and Type
Amount you owe
PART 4.4 BANKRUPTCY (if relevant)
4.4a Bankruptcy Status
Are you currently bankrupt or have you filed for bankruptcy?
Yes
No
If you answered yes, when did you file?
___________________ (dd/mm/yyyy)
4.4b Debt Agreement
Are you currently engaged in a debt agreement?
Yes
No
If you answered yes, when was this approved?
___________________ (dd/mm/yyyy)
PART 5 – ASSETS
Do you own or are you currently purchasing any of the following? Please select and provide information for all that apply.
House
Address
Land
Address
Other
Address
PART 6 – FURTHER INFORMATION
Please provide any additional information / supporting evidence including the housing reference (PART 1.4)
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