Current Start Preview Complete Information message Filling out this form will email the relevant department Your details Name Customer name Title Title - Select -MissMsMrMrsDrOther…- Select -▾- Select -MissMsMrMrsDrOther… Enter other… First name Last name Address Customer address First line of address Second line of address City/Town Postcode Contact Contact details Email Phone number Other details Bidding/Application number? National Insurance Number Your gender? Woman Man Non-binary I use another term Prefer not to say Date of birth Medical details What are your medical conditions or disabilities? What medication are you taking? Do you need to upload any supporting documents? Yes No Supporting evidence upload? Doctor details Name Doctor name Title Title - Select -MissMsMrMrsDrOther…- Select -▾- Select -MissMsMrMrsDrOther… Enter other… First name Last name Address Doctor address First line of address Second line of address City/Town Postcode Contact Doctor contact details Email Phone number Property details Property type Type of property House Bungalow Flat Maisonette Other… Enter other… Type of house/bungalow Terrace Semi-detached Detached Other… Enter other… Flat details Floor number Is there a flat? Yes No Room details Number of bedrooms Additional information How does your current home affect your illness and how would a move help? Declaration Under Section 160a of the Homeless Act 2002 the council may refuse rehousing to those applicants and family members who have a history of serious anti-social behaviour. The council have a policy to work with the Community to reduce anti-social behaviour and to improve the prevention and detection of crime. I/we confirm that the information given on this form is correct and that if I/we have given false or misleading information the council or its managing agents are entitled to take legal action if any person obtains, or attempts to obtain, accommodation as a result of giving false or misleading information. I/we understand I must notify the council of all changes affecting my/our application as soon as they occur. This includes any changes to contact details and changes in my/our housing circumstances. I/we authorise you to undertake appropriate checks to verify the information I/we have provided at all stages in my/our application for housing, including sharing information with the Housing Benefits department, any other council department, any other council, registered social landlord, private landlord or managing agents, Department of Work and Pensions, West Midlands Police, National Fraud Initiative, NHS, employers, or any other agencies. Any personal information will be processed in accordance with the requirements of the General Data Protection Regulations or any subsequent data protection legislation. For more information on how we use and share your information please refer to our Privacy Notice which is on the Wolverhampton Homes website. However, if you would like a written copy of this please contact any Wolverhampton Homes Office. I/We understand that any landlord may take legal action, under the Housing Act 1985, if any person obtains accommodation as a result of giving false or misleading information. This authority is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing and administering public funds for these purposes. 18590
