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8DEPARTMENT OF HOUSING
www.nt.gov.au
Housing application form
If you wish to apply for public housing, please:
Office use only
1. Complete this form in BLOCK LETTERS in blue or
Received by
....................................................................................
black pen.
Territory Housing office
..............................................................
2. Provide proof of income and bank balance for all
Date
...................................................................................................
household members over 18 years of age.
Group no.
TRIM no.
..................................
...............................
3. Attach all documents requested in the application.
Application checklist
4. Sign the application.
Identification
Yes
No
5. Lodge the application at your nearest housing office or
Proof of residency
Yes
No
email to housingwaitlist@nt.gov.au.
Proof of income
Yes
No
Note: All information you declare in this application will
Bank statements / ATM slip
Yes
No
remain confidential.
Assets
Yes
No
Do you require an interpreter to help you complete this
Property ownership
Yes
No
form?
Previous tenant or applicant
Yes
No
(if yes above please provide group no.)
..............................................
No
Yes
If yes, please indicate your preferred language:
........................................................................................................................
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Location
Please select the area in which you would prefer to be
housed:
Darwin
Casuarina
Palmerston
Tennant Creek
Nhulunbuy
Katherine
Alice Springs
Part A – Household details
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Applicant details
Please circle: Mr / Mrs / Ms / Miss
First name:
......................................................................................
Alternative name(s):
Last name:
................................................................................
......................................................................................
Gender:
Male
Female
Date of birth:
...................................................................................
Are you of Aboriginal or Torres Strait Islander origin?
Aboriginal:
Yes
No
Torres Strait Islander:
Yes
No
Do you have a disability?
Yes
No
If yes, select your type of disability (select as many boxes as required)
Psychiatric
Physical
Intellectual
Sensory
Other:
.............................................................................................
SF31 updated: 09/12
1
DEPARTMENT OF HOUSING
www.nt.gov.au
Housing application form
If you wish to apply for public housing, please:
Office use only
1. Complete this form in BLOCK LETTERS in blue or
Received by
....................................................................................
black pen.
Territory Housing office
..............................................................
2. Provide proof of income and bank balance for all
Date
...................................................................................................
household members over 18 years of age.
Group no.
TRIM no.
..................................
...............................
3. Attach all documents requested in the application.
Application checklist
4. Sign the application.
Identification
Yes
No
5. Lodge the application at your nearest housing office or
Proof of residency
Yes
No
email to housingwaitlist@nt.gov.au.
Proof of income
Yes
No
Note: All information you declare in this application will
Bank statements / ATM slip
Yes
No
remain confidential.
Assets
Yes
No
Do you require an interpreter to help you complete this
Property ownership
Yes
No
form?
Previous tenant or applicant
Yes
No
(if yes above please provide group no.)
..............................................
No
Yes
If yes, please indicate your preferred language:
........................................................................................................................
1
Location
Please select the area in which you would prefer to be
housed:
Darwin
Casuarina
Palmerston
Tennant Creek
Nhulunbuy
Katherine
Alice Springs
Part A – Household details
2
Applicant details
Please circle: Mr / Mrs / Ms / Miss
First name:
......................................................................................
Alternative name(s):
Last name:
................................................................................
......................................................................................
Gender:
Male
Female
Date of birth:
...................................................................................
Are you of Aboriginal or Torres Strait Islander origin?
Aboriginal:
Yes
No
Torres Strait Islander:
Yes
No
Do you have a disability?
Yes
No
If yes, select your type of disability (select as many boxes as required)
Psychiatric
Physical
Intellectual
Sensory
Other:
.............................................................................................
SF31 updated: 09/12
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Contact details
Home phone:
Work phone:
....................................................................................
...............................................................................
Mobile phone:
Email address:
..................................................................................
..............................................................................
Residential address
Address:
Postcode:
..................................................................................................................................................................
..................................
Postal address (if different from residential address, or if you expect to leave your current address)
Address:
Postcode:
..................................................................................................................................................................
..................................
Additional contact information:
.......................................................................................................................................................................
..............................................................................................................................................................................................................................................
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Next of kin
In case we are unable to contact you, please supply details for a person who could help us reach you.
Full name:
Relationship to you:
.................................................................................................................
........................................................
Address:
Postcode:
..................................................................................................................................................................
.................................
Home phone:
Work phone:
....................................................................................
...................................................................................
Mobile phone:
Email address:
..................................................................................
..............................................................................
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Previous accommodation
Have you, or any other person named in this application, previously been a public housing tenant in the
Northern Territory?
Yes
No
If yes, when?
...................................................................................................................................................................................................................
Where did you/they live?
.........................................................................................................................................................................................
Why did you/they leave?
..........................................................................................................................................................................................
Please list the accommodation you have lived in during the past 12 months.
Dates
Address
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Household member details
Have you, or any person to be housed with you, been known by another name(s) in the past?
(e.g. name changed by deed poll, marriage or divorce)
Yes
No
If yes, please list the name of each person and their past names:
....................................................................................................
..............................................................................................................................................................................................................................................
You will need to provide suitable identification for every household member as well as evidence of your
household structure. For example:
• Marriage certificate, statutory declaration of de facto relationship
• Birth certificate, custody papers or proof of receipt of Family Tax Benefit payment for custody of children
and/or dependants.
Please refer to Section 12 for further examples of supporting documentation.
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Please give details of all the people who live with you. Do not repeat information for you or your partner if the
same information is already recorded on this application.
If you require additional space, please write on another piece of paper and attach to this form.
Household member
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Title
Mr / Mrs / Ms / Miss
Mr / Mrs / Ms / Miss
Mr / Mrs / Ms / Miss
First name(s)
Surname
Relationship to you
(e.g. son, daughter)
Sex
Male
Female
Male
Female
Male
Female
Date of birth
/
/
/
/
/
/
Contact phone number
Aboriginal
Yes
No
Yes
No
Yes
No
Torres Strait Islander
Yes
No
Yes
No
Yes
No
Disability
Yes
No
Yes
No
Yes
No
If yes, please specify
Psychiatric
Physical
Psychiatric
Physical
Psychiatric
Physical
Intellectual
Sensory
Intellectual
Sensory
Intellectual
Sensory
Other:
Other:
Other:
........................................
........................................
........................................
Household member
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Title
Mr / Mrs / Ms / Miss
Mr / Mrs / Ms / Miss
Mr / Mrs / Ms / Miss
First name(s)
Surname
Relationship to you
(e.g. son, daughter)
Sex
Male
Female
Male
Female
Male
Female
Date of birth
/
/
/
/
/
/
Contact phone number
Aboriginal
Yes
No
Yes
No
Yes
No
Torres Strait Islander
Yes
No
Yes
No
Yes
No
Disability
Yes
No
Yes
No
Yes
No
If yes, please specify
Psychiatric
Physical
Psychiatric
Physical
Psychiatric
Physical
Intellectual
Sensory
Intellectual
Sensory
Intellectual
Sensory
Other:
Other:
Other:
........................................
........................................
........................................
Are any of the household members on the application expecting a child?
Yes
No
If yes, name of the person/s:
Expected due date:
..................................................................................................
....................................
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Part B – Income and assets details
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Household income details
Please provide evidence of the gross weekly income (before tax) for all household members aged 18
years and over. Attach documents to confirm income received over the past three months as follows:
Wages: payslips for thirteen (13) consecutive weeks or a letter from your employer confirming gross (before
tax) income.
Government pension, benefit or allowance (including Family Tax Benefit Part A): a statement no more
than two weeks old, showing pension, benefit, allowance received from Centrelink, Veterans Affairs or other
agencies.
Self-employed: provide previous financial year’s tax notice of assessment from the Australian Taxation Office.
Please discuss this with a Territory Housing Officer if your business has been operating for less than 12 months.
Income from any other source (e.g. Workers Compensation): a letter or statement of other documentation
that confirms both the source of income and the gross (before tax) amount.
Note: if you are claiming child maintenance payments as exempt income you will need to provide proof of
your payments (such as pay slips, confirmation from the Child Support Agency, or Statutory Declarations
from both parties).
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Statement of assets
Please provide a statement of assets of all household members aged 18 years and over. Attach
documentary evidence of those assets and any loans against them. If any of these assets cannot be
accessed (such as superannuation) you will need to provide supporting documentary evidence.
Normal household goods (furniture, white goods, TV etc.), personal items (clothing etc.) and one family
vehicle are not counted as assessable assets. Assessable assets include high priced saleable items,
financial investments and cash savings.
All bank accounts
Account holder’s name
Bank and branch
Account number
Amount ($)
Fixed term deposits
Account holder’s name
Bank and branch
Account number
Amount ($)
Shares investments (include accessible superannuation funds)
Account holder’s name
Name of shares/funds
Current value ($)
Motor vehicle
Owner’s name
Make and model
Estimated current value ($)
Amount owed ($)
Property and land / mobile home / boat / caravan / any other valuable saleable items
Owner’s name
Description of assets
Estimated current value ($)
Amount owed ($)
If you require additional space, please write on another piece of paper and attach to this form.
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Part C – Housing requirements
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Current housing situation
Where do you currently live?
Please select all situations that apply to your household:
Community housing
Renting privately
Hotel/motel
Sleeping in the park/river/saltbush/long grass
Refuge, emergency or crisis housing
Living or squatting in a makeshift or illegal building
Living with family or friends
Hostel
Boarding house
Caravan park
Correctional facility
Living in a remote community
Other. Please specify:.......................................................................................................................................
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Housing need
Why is your current accommodation unsuitable?
Please select all situations that apply to your household:
One or more household members are homeless
There are serious social problems within your household (this may include overcrowding or family breakdown)
Your current housing is unsafe due to domestic and family violence
A household member has serious medical problems that affects your ability to secure private housing
Your current housing lacks essential facilities (e.g. cooking, bathroom, water supply, lighting)
Your current housing location is preventing a household member accessing required essential care or
medical services
Your family unit needs to reunite as they are currently living apart
If you have ticked any of the above boxes, you may be eligible for Priority Housing. Please complete a Priority
Housing application form (SF28) to support your housing application.
None of the above applies to me
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Support
If you or another household member are receiving support from an organisation or individual, and would
like them to update your details on this housing application, please complete an Authority for Advocate
Representation form (SF12). This will allow your support organisation/support person and Territory Housing
to share information that is relevant to your housing application. This will help to ensure that this application is
accurate and up to date.
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Additional housing services
Do you also wish to apply for:
Community housing
(rental housing provided and managed by non-government and community organisations)
Managed and supported housing
(community housing with additional support services such as counselling and life skills training)
If you have ticked any of the above boxes, you will need to complete Section 15 to allow Territory Housing to
share your information with community housing providers.
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