Almshouses provide affordable accommodation to people who might otherwise not have the means, and who meet the criteria set down by the particular Almshouse charity’s Governing Document.

Please return your completed application form to PBE properties Limited 76 Hesleden Avenue, Acklam, Middlesbrough TS5 8RN pbeproperties.co.uk

Data Protection Statement: it is part of the Trustees’ responsibilities to ensure that applicants for almshouses are suitably qualified under the terms of the charity’s governing document. Trustees, therefore, need to investigate the personal circumstances of applicants. The personal data supplied on this form and other information relating to an almshouse appointment or your care management will be held on file. Some details may be checked with relevant organisations since the charity reserves the right to investigate and verify what you write in this form, but no details will be disclosed for any inappropriate purpose. You may have access to your personal information on request.

About You

Full name (inc title)

Current address

Length of time at this address

Telephone number

Email address

Date of birth

Marital status

National insurance number

Employment history

Employer

Location

About your job

About Your Current Address

Describe accommodation

(e.g. 3 bedroom house, 2 bedroom apartment)

Do you own it

If yes, please inform us of the estimated value:

Outstanding mortgage

Is there an outstanding mortgage? If yes,

If you do not own property

If you do not own the property, who does? Are you related to that person in any way? If so, how?

If you once owned property

If you did once own the property, please inform us the circumstances of ceasing to own it:

If property is rental

If the property is a rental, please provide the name and address of the Landlord:

Current rent per week

Do you receive Housing Benefit to assist you with living costs

Do you receive Council Tax discount?

Why do you wish to leave this accommodation?

Own any other property

Do you own any other properties, either within the UK or abroad? If yes, please provide details.

Section 4 – Your Preferred Almshouse

Please inform us of your preferred Almshouse in numerical order – 1 being the most preferred and 8^th being the least. We will aim to get you placed into your preferred, however, this is subject to availability.

Please ensure you have read & understood the requirements for living at your preferred Almshouse. Copies of handbooks can be obtained from PBE Properties Limited on paul@pbeproperties.co.uk or 07780 257578

Slect preferred Almshouse

Section 5 - Your income

To enable Trustees to assess your application, please provide the following information as factually as you can. Please ensure all sources of income are stated, along with the frequency.

Bank Account – Current Bank Balance

Buildings Society – Current Bank Balance

Shares – Current Value

Employment/Self employment

Employment/Self- Employment

Please explain the type of employment & hours of the work. N.B: You will be required to bring evidence of earnings, such as payslips or Proof of Earnings to the interview.

Other income

Annuities

Bank deposit account

Buildings Society account

Investment

Renting out a property or land you own

Charity grants

Financial assistance

from a friend or relative

Your capital

Do you have any loans/debts

Do you have any loans or other outstanding debts? If yes, please provide details.

Income

State retirement pension

Private Pension

Pension Paid by Past Employer 4. Widow/Widowers

Any other pension

Social security benefit

Pension credit

Attendance allowance

Universal credit

Any other benefit

Your capital

National savings

Unit trust - Current value

Premium bonds - Amount held

Health and social factors

Are currently living independently

Please provide details of any significant illnesses/operations in the last 5 years.

Are you currently receiving any treatment

If yes, please provide details.

Are there any health or social factors that you wish to inform the trustees of

If yes, please provide details.

References

Please provide the names of two referees who you wish the charity to approach for a reference, and how you know them. These referees cannot be relatives. If you are currently renting a property, you should provide your Landlord as a reference.

Reference 1

Full name

Contact telephone

Address

Reference 2

Full name

Contact telephone

Address

Almshouse Application Form

Section 9 – Declaration

I declare that the information given in this application is correct & complete to the best of my knowledge and belief.
I understand that Trustees would be entitled to terminate any appointment to an Almshouse dwelling I may be given as a result of this application having untrue or misleading answers in any respect.
I have read the application form carefully & agree to abide by this should I be appointed an Almshouse.
I accept that if I am appointed as a resident, I shall be a beneficiary of the charity and not a tenant. Any weekly sum I pay will be a maintenance contribution and not a rent.
I confirm that I am able to look after myself and to live independently, with the assistance of family and social services if necessary.
I consent to my GP or other medical attendant providing the charity with a medical certificate or report about my health and condition now or at a future date in accordance with the terms of the attached form of authority.
I consent to the charity holding personal data on this form in accordance with Data Protection Regulations.