About the information you give
The applicant's information requested on this form is required under the Housing Assistance Act 2007. The information the organisation provides will be treated confidentially and used to assess their entitlement to housing assistance and for statistical purposes. This information may be disclosed by Housing and Community Services as required by law. The organisation may have access to any information they provide to ensure that it is still accurate, and to allow them to correct it if necessary. It may be necessary to disclose this information to anybody reconsidering a decision in relation to the application. For further information on storage and use of the organisation's information, please ask for a privacy statement from a Housing and Community Services officer.

Step 1
Complete the form overleaf.

Print neatly in BLOCK LETTERS.

Make sure all relevant questions are answered, otherwise we may have to return the form to the organisation to be completed.

If assistance is required to complete the form, ask an officer of Housing and Community Services to help, or call 6207 1341.

Step 2
Make sure the organisation has all the required documents. 

The application cannot be completed until all documents have been presented.

Step 3
Lodge the application with Housing and Community Services.  Alternatively the application and all required documents can be posted to:

Housing and Community Services
Social Housing and Homelessness Services
Locked Bag 3000
Belconnen  ACT  2616

The organisation will be advised of the outcome of their application within 28 days of receipt.

1 Organisation Information	
				
Organisation Name		Contact Name		
				
Street Address		Secondary Contact		
		BH Phone		
				
Postal Address		AH Phone		
		Mobile		
				
Email address		Fax		
				
2 Organisation Structure	
				
Type of Association		Incorporated Community Organisation		Government Agency	
		Private Organisation			
				
Other		
				
Is the organisation registered? (Attach registration if not already provided)			YES		NO	
				
Type of organisation		Non-Profit Community Organisation	
		Administrative Unit	
		Territory entity under the Auditor-General Act 1996	

What are the objects of the 
organisation's constitution?
(Attach constitution if not already provided)		

				
Does the organisation have an appropriate system of management in place? 
(Attach organisational structure, etc if not already provided)		

				
3 Services and Support	
				
Does the organisation provide tenancy services and tenant support?			YES		NO	
				
Does the organisation provide crisis and/or transitional supported accommodation?			YES		NO	
				
Does the organisation provide a range of related support services to people, including people who are homeless or at risk of homelessness?			YES		NO	
				
Does the organisation facilitate long-term accommodation and support services?			YES		NO	
				
Does the organisation provide temporary, short-term housing needs to people transitioning from supported accommodation to independent living?			YES		NO	

3 Services and Support (continued)	
				
Does the organisation provide other forms of services?			YES		NO	
				
If YES, specify		

				
Do other services or organisations provide support to the clients who will be accommodated under this proposal?			YES		NO	
				
If YES, specify		

				
4 Property Use	
				
Will the property be used for residential purposes?			YES		NO	
				
If NO, specify property use		

				
5 Declaration	
				
Declaration by Organisation’s agent / representative

Please note providing false or misleading information may lead to legal penalties.	I declare as the organisation’s agent / representative,  the information given in this application is complete and correct	
	Signature		
	Date	
	/		/		

	

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