Apply for extra care housing

Third party details
Please provide contact information if you are filling in this form on behalf of someone else
Name

First name

Last name
Phone
What is your relationship to the applicant(s)?

Current needs - applicant 1
Do you currently receive support or care?
If yes, who do you currently receive support from?
Social workerCare agencyAny other agencyFamily or friends
If yes, how many hours of care and support do you receive each week?

Contact details of person who provides support - applicant 1
Please provide the contact details for any support provider or social worker who works with you.
Name of support provider or social worker

First name

Last name
What organisation do they work for?
Address
Postcode
Phone
Email
Do you have another person who provides support? If yes, please provide information below

Please provide details of the care/support you already receive or support that you will need
Are you disabled?
If yes, please provide more information

Are there any other medical circumstances that may affect your housing needs? For example, mental health. If so, please give details below:
Do you have any adaptations in your home? If yes, what are they? If no, what adaptations do you need?

Income - applicant 1
Do you currently receive any of the following:
IncomeState pensionOccupational pensionBenefitsWagesOther incomeSavingsOther investmentsNone
If you receive Benefits, please list them
Which Extra Care housing scheme is your 1st choice?
Which Extra Care housing scheme is your 2nd choice?
Which Extra Care housing scheme is your 3rd choice?
Additional information:

Current needs - applicant 2
Do you currently receive support or care?
If yes, who do you currently receive support from?
Social workerCare agencyAny other agencyFamily or friends
If yes, how many hours of care and support do you receive each week?

Contact details of person who provides support - applicant 2
Please provide the contact details for any support provider or social worker who works with you.
Name of support provider or social worker

First name

Last name
What organisation do they work for?
Address
Postcode
Phone
Email
Do you have another person who provides support? If yes, please provide information below

Please provide details of the care/support you already receive or support that you will need
Are you disabled?
If yes, please give more information

Are there any other medical circumstances that may affect your housing needs? For example, mental health. If so, please give details below:
Do you have any adaptations in your home? If yes, what are they? If no, what adaptations do you need?

Income - applicant 2
Do you currently receive any of the following:
IncomeState pensionOccupational pensionBenefitsWagesSavingsOther incomeOther investmentsNone
If you receive Benefits, please list them
Which Extra Care housing scheme is your 1st choice?
Which Extra Care housing scheme is your 2nd choice?
Which Extra Care housing scheme is your 3rd choice?
Additional information

Applicant declaration
Declaration and authority to obtain details from another agency. Agreeing to the declaration below means that you agree to the terms and conditions listed in sections 1 and 2. All information provided by either yourself or a third party will be used for the sole purpose of enabling Wigan Council to assess your application for housing in accordance with the Council's Extra Care Housing Allocation Policy and the General Data Protection Regulation 2018.
Section 1
I understand that Wigan Council will decide whether to nominate me for a tenancy in an Extra Care Housing Scheme based on the information that I have given on this form. The information that I have given is true and correct to the best of my knowledge. I understand that if I give false or misleading information or do not provide relevant information, my application will not be considered. I understand Wigan Council, or any partner agency such as Housing Association can take back any tenancy they have given me if I have provided false information. I will tell Wigan Council if my circumstances change.
I agree

Section 2
I understand that Wigan Council may need to contact other agencies for information about me so they can process my application and assess my suitability to be a tenant in Extra Care Housing. This could include contacting Housing Benefits and Council Tax, other landlords, the Benefits Agency, Probation Service, the Police and Social Services. I give permission for Wigan Council to contact any relevant agencies, including present and/or former landlords. I give these agencies permission to share information they hold on me with Wigan Council so that they can deal with my housing application and any future tenancy. I understand that even if I do not agree to allow this, some information can still be shared to prevent and detect fraud or if it is to stop me committing crime.
I agree

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