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Housing Assistance Enquiry

This form is to help us decide whether you may be eligible for financial assistance for work at your home.

It is not an application form.

When we have the information, we should be able to tell you if you qualify. If you do we will advise you about making a full application.

We know that some of the information we ask for is very personal. However, we are trying to make sure our grants go to people and homes in most need. Therefore, we give our assurance that any information you do provide will be used only to assess whether you are eligible for a grant. If you do not proceed, the information you give will be destroyed.

Part 1. Personal Details.

Please be aware that the following data will only being used to respond to this email and for no other purpose. Note: Ficticious details will be treated appropriately.

Your Name: 

Property Number/Name: 

Street: 

Town/City: 

County: 

Post Code: 

Telephone: 

Email Address: 

Your age: 

 I am under 60 years of age.
 

 I am 60 (or over) years of age
Are you: 

How many dependant  
children do you have? 

   Their ages:

Part 2. Your Financial Details

Do you or your husband/wife/partner receive any of the following:-

 Income Support or Income Based Job Seekers Allowance

Housing Benefit

Council Tax Benefit (NOT Council Tax reduction)

Working Tax Credit )
)
)		 Is your income less than £15460
per year? Yes or No

Child Tax Credit

Do you or your husband/wife/partner receive any of the following:-

 Disability Living Allowance

Attendance Allowance

War Disablement Pension

Industrial Injuries Benefit
Do you receive any other benefits? Please state: 

Only complete the next question if you are over 60

If you are over 60 and you do not receive a benefit listed above, you may still qualify for assistance. Please tick if either of the boxes below apply:-

Note: Your capital does not include the value of the home you live in.
I live alone, my total weekly income is less than £150.00 and my total savings/investments/capital is less than £16,000


I live with my husband/wife/partner, our total weekly income is less than £200.00 and our total savings/investments/capital is less than £16,000

Part 3. The Home You Are Enquiring About

 If the address is the same as above, tick this box
Property Number/Name: 

Street: 

Town/City: 

County: 

Post Code: 

Is the home  
currently empty?: 		 Yes or No?
Do you own it?  or are you intending to buy?
How long have you  
lived there? 

Do you live in the  
property at the moment? 		  YES Yes or No?
Tell us briefly the sort of work you would like to apply for: 
How is your home affected by the work that needs doing?
(Examples might be roof leaking into bedroom, possible danger from
electrics, no heating, no hot water and so on): 

Part 4. Declaration

I declare that the information given above is correct to the best of my knowledge. I understand it will be used to assess whether I may qualify for any grant and that if I apply, the Council will ask for proof of my personal and financial circumstances. I further understand that this is NOT a full grant application and that the Council has made no promise that I will receive any grant.
Your name: 

Date: 

In leiu of a signature please tick the box below to confirm the above information is correct. You will be expected to formally sign should your application be successful.
Signature: 

After completing this form click 'Submit Form' at the bottom of this page.

Your Information
Please read this before sending your response

Where you provide personal data to us, such data will be used only for the purpose for which you have submitted it.

If you are a user with general public and anonymous access the Oadby and Wigston Borough Council web site does not store or capture personal information but merely logs the user's IP (Internet Protocol) address that is automatically recognised by the web server

We do not use cookies for collecting user information and we will not collect any information about you except that required for system administration of our web server.

This privacy statement only covers our web site including pages found at http://oadby-wigston.gov.uk and http://owbc.net. This statement does not cover links within this site to other web sites.

  Return to Top Author: Environmental Health Updated: 12 March 2007  
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