Housing Allowance Application Form for Tenants

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_________________________________________________________________________
HOUSING ALLOWANCE APPLICATION FORM FOR TENANTS
INSTRUCTIONS
1
Employees who are/became tenants on or after 1 January 2005 should complete this application form.
2
Complete and tick the boxes that apply to you.
3
Please see the list of ducuments in Section B, which must be attached to your application. If necessary please
refer to the Employee Guide on the Housing Allowance for physical examples.
4
Ensure that you have completed and signed the form and attached all the documents required since lacking
information may delay the payment of your application.
5
If you experience difficulty to complete this application form, please do not hesitate to contact your personnel
office for assistance.
SECTION A: PERSONAL DETAILS
EMPLOYEE’S DETAILS
Surname
Initials
Department
Component
ID No
PERSAL No
Contact No
Work
Home
Cell
SPOUSE’S DETAILS
Surname
Initials
ID No
Employer
Work address
Contact No
Work
Home
Cell
_________________________________________________________________________
HOUSING ALLOWANCE APPLICATION FORM FOR TENANTS
INSTRUCTIONS
1
Employees who are/became tenants on or after 1 January 2005 should complete this application form.
2
Complete and tick the boxes that apply to you.
3
Please see the list of ducuments in Section B, which must be attached to your application. If necessary please
refer to the Employee Guide on the Housing Allowance for physical examples.
4
Ensure that you have completed and signed the form and attached all the documents required since lacking
information may delay the payment of your application.
5
If you experience difficulty to complete this application form, please do not hesitate to contact your personnel
office for assistance.
SECTION A: PERSONAL DETAILS
EMPLOYEE’S DETAILS
Surname
Initials
Department
Component
ID No
PERSAL No
Contact No
Work
Home
Cell
SPOUSE’S DETAILS
Surname
Initials
ID No
Employer
Work address
Contact No
Work
Home
Cell
For Official
SECTION B: RENTAL STATUS
Use
Reference
I am a tenant
Tick the
Proof to be attached
Tick the
Proof is
code
because -
applicable
to this application
applicable
attached
box
form
box if
proof is
attached
Yes
No
Yes
No
R1
I pay occupational rent
Offer to purchase/
to the person I am
Deed of Sale which
buying my home from
includes the
occupational rent
clause
R2
I rent a home from a
Rental Agreement
private landlord/
municipality
R3
I rent a home from
Rental Agreement
family or friends
R4
I am obliged to occupy
Rental Agreement
and rent State Housing
as defined in Part XVI
of Annexure B to
PSCBC Res. 3 of 1999
R5
I am voluntary
Rental Agreement
occupying and renting
Other Housing in terms
of a departmental
policy defined in Part
XVI of Annexure B to
PSCBC Res. 3 of 1999
For Official
SECTION D: OCCUPANCY DETAILS
Use
The home is occupied by -
Tick the
Proof to be attached
Tick the
Proof is
applicable
to this application
applicable
attached
box
form
box if
proof is
attached
Yes
No
Yes
No
Myself
A sworn affadavit
My spouse
My dependants
My spouse and dependants
Date of Occupancy
The full residential address of the home is:
SECTION E: CONFIRMATION, ACKNOWLEDGEMENT, UNDERTAKING AND DECLARATION
I the undersigned,
(a) Confirm that the information in this application form is accurate.
(b) Acknowledge that I could be disqualified from the Home Allowance Scheme should the information provided be false
and/or inaccurate in which event the employer may recover any monies over paid and institute disciplinary action
and/or lay criminal charges (depending on the seriousness of the situation).
(c)
Undertake to inform the employer should there be any changes in my situation as a home owner and occupancy of my
home; and
(d) Declare that the home is occupied as indicated in the form.
________________________________
______________________________________
Employee Signature
Date
FOR OFFICE USE ONLY
Employee Persal No
Employee is a tenant in category
R1
R2
R3
R4
R5
Do not
comply
The home is occupied according to the
Yes
No
Do not
requirements in the Determination on Housing
comply
Application for Housing Allowance is –
Approved
PERSAL Code assigned
Corresponding
Reference Code in Section
(tick the applicable code)
B
0547
Rental
(R1 – R5)
OR
Declined
Reasons (if declined)
Signature of official
authorised to
aproved the Housing
Allowance
Name in print
Designation
Date
INSTRUCTIONS
Inform employee of the outcome of his/her
Prepare decline letter with reasons
application
Prepare letter of approval
Capture on PERSAL

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