Registration to apply for Social Housing Assistance in the ACT

Use this form to apply for social housing assistance in the ACT.
Social housing assistance includes:
•  public housing which is provided directly by Housing ACT;
•  community housing which is provided by community housing organisations  funded by the ACT Government; and
•  affordable housing - where the rent payable is less than the full market rent.
Do you wish to be considered for: (a) 	Public housing
(b) 	Community housing
(c)	Affordable housing
(d) 	All of the above

If you have selected (b) or (c) or (d), you are giving consent for your personal details relevent to your application, to be given to a 
community housing organisation.

Do you wish to be considered for shared accomodation?

Step 1
Complete the form overleaf. 
Print neatly in BLOCK LETTERS.
Make sure you answer all relevant questions, otherwise we may have 
to return the form to you to be completed. 
If you need help with the form, ask an officer of Housing ACT to help 
you or call 6207 1150. 
If you need help in a language  other than English, complete as much of the form as you can. When you lodge your form, Housing ACT will contact the Telephone Interpreter  Service (TIS) to assist.
Step 2
Complete the accompanying forms (if applicable). 
If you have been employed in the last 26 weeks you may need your employer to complete the Income Statement  from Employer on page 6 before you lodge this form. 
If you receive payments  from Centrelink or the Family Assistance Office, you must complete the Consent for Centrelink to provide a Statement  of Income on page 7 before you lodge this form. 

If anyone on this form receives support from an agency or organisation and that person allows Housing ACT to contact their support person/ agency to discuss this registration, the Consent to Exchange and Release Information on page 8 must be completed before you lodge this form.

Step 3
Make sure you have all the required documents. 
Please see the ‘Applying for Social Housing’ Fact Sheet and the 
Supporting Documentation Checklist.

Step 4
Lodge your application at Gateway Services or call 6207 1150 or ask a 
staff member. 
Alternatively you can post your completed form and all the required 
documents to: 

Housing  ACT Locked Bag 3000
Belconnen  ACT 2616

Accessibility	
The ACT Government is committed to making its information, services, events and venues, accessible to as many people as possible.	
If you have difficulty  reading a standard printed document and would like to receive this publication in an alternative format — such as large print or audio—please  telephone (02) 6205 0619	
If English is not your first language and you require the translating and interpreting  service — please telephone 131 450.	
If you are deaf or hearing impaired and require the
TTY typewriter  service — please telephone (02) 6205 0888	

AF2012-189 Housing Assistance Act 2007, s 39

F00591(1211)

Personal details	Applicant 1	Applicant 2	
1 	Title 	Mr	Mrs	Ms	Miss	Dr	Mr	Mrs	Ms	Miss	Dr	

2 	Your full name

3 	Date of birth	

/ 	/ 	Sex	

/ 	/ 	Sex	

4 	Address where you currently live	

Postcode	

Postcode	

5 	Postal address (if different to the address where you currently live.)	

Postcode	

Postcode	

6 	Your contact details

Email address			

7 	What is your relationship to the other applicant named on this form?
(if applicable)			

8 	Are you a permanent resident of Australia?	Yes	Go to Question 10
No	Are you currently  a sponsored migrant to
Australia?

No 	Yes	Please attach
evidence	Yes	Go to Question 10
No	Are you currently  a sponsored migrant to
Australia?

No 	Yes	Please attach
evidence	

9 	Have you lived in the ACT
for more than six months?	Yes 	Please attach evidence
No	(if No you may not be eligible for Housing Assistance. Please speak to a Housing officer if you are unsure).	Yes 	Please attach evidence
No	(if No you may not be eligible for Housing Assistance. Please speak to a Housing officer if you are unsure).	

10     Do you have a current application for housing assistance?	No
Yes 	What name is the application in?	No
Yes 	What name is the application in?	
Are you of Aboriginal  or Torres Strait Islander origin?
11      (These questions  are optional  and  will be used for statistical purposes only unless you are applying for Aboriginal and Torres Strait Islander Community Housing)
No	Yes - Aboriginal

Yes - Both	Yes - Torres Strait Islander

Your preferred language

Country of birth	

No	Yes - Aboriginal

Yes - Both	Yes - Torres Strait Islander	

12     Provide details of someone we can contact if we are unable  to contact you (Emergency or Third party contact)
If possible, please list someone who lives in the ACT

Name

Address

Postcode

(H)	
(W)	
(M)	
(E)	

(H)	
(W)	
(M)	
(E)	

AF2012-189

Telephone

13    Indicate your Housing requirements
(Please attach evidence)
Location - see property allocations  zone map
Disabled modifications
Other

Other Residents

14      Will  any other  people  live  in the  Housing  ACT Property  with  you permanently (including children)?
Please provide evidence to confirm ongoing child contact arrangements.
(ie. family court orders, care and protection advice, separate parental agreement etc.)

No 	Yes	Give details below

Full name 	Date of birth 	Relationship 	ID provided 	Contact	Proof of Contact

No	Yes	No	Yes	No	  Yes
No	Yes	No	Yes	No	  Yes
No	Yes	No	Yes	No	  Yes
No	Yes	No	Yes	No	  Yes
No	Yes	No	Yes	No	  Yes
No	Yes	No	Yes	No	  Yes

Income	Applicant 1	Applicant 2	
15     Do you currently 	No
receive Centrelink or	Yes 	 Please complete the Consent for Centrelink Family  Assistance Office 			to provide a Statement  of Income on benefits?			page 7 OR provide  a Centrelink Income
Statement  for Housing Authorities	No
Yes 	Please complete the Consent for Centrelink to provide a Statement  of Income on
page 7 OR provide  a Centrelink Income
Statement  for Housing Authorities	

16     Are you currently employed?

17     What is your gross income? (ie before tax)?
Include wages and pension payments	
No
Yes 	Please complete the Income Statement from Employer on page 6 or provide payslips for the last 26 weeks when you lodge this form.

Per week	Per fortnight

$	OR	$	
No
Yes 	Please complete the Income Statement from Employer on page 6 or provide payslips for the last 26 weeks when you lodge this form.

Per week	Per fortnight

$	OR	$	

18     Do you receive any other income (e.g. overseas pension, interest on bank accounts, child support payments)?	
No
Yes	How  much do you receive?
Per week	Per fortnight

$	OR	$	
No
Yes	How  much do you receive?
Per week	Per fortnight

$	OR	$	

AF2012-189

19      Do you PAY any child support?	
No
Yes	How  much  do  you  pay?
Per week	Per fortnight

$	OR	$

Please attach evidence of how much you pay such as a letter from the Child Support  Agency (CSA).	
No
Yes	How  much  do  you  pay?
Per week	Per fortnight

$	OR	$

Please attach evidence of how much you pay such as a letter from the Child Support  Agency (CSA).	
Page 3

	$	
	$	

	$	
	$	

	$	
	$	

	$	
	$	

Assets	
Personal details	Applicant 1	Applicant 2	
20     Do you have any bank, 	No
building  society or credit 	Yes	How  many   do  you  have?
union accounts?
Please attach the documents outlined in
the Housing ACT Fact Sheet – Acceptable Forms of Bank Statements	No
Yes	How  many   do  you  have?

Please attach the documents outlined in the Housing ACT Fact Sheet –
Acceptable Forms of Bank Statements	

21     Do you have any investments  such as shares or bonds?	
No
Yes 	Please attach evidence of your investments	
No
Yes 	Please attach evidence of your investments	
Personal details	Applicant 1	Applicant 2	

22    Do you own any cars or other vehicles, including boats, caravans etc?	
No
Yes	Give details
Type (e.g. car)	Value	
No
Yes	Give details
Type (e.g. car)	Value	

23     Do you own or hold an interest in any residential or business property
in Australia?	
No
Yes	Give details and attach evidence of ownership of the property
Name of owner(s)

Address of the property	
No
Yes	Give details and attach evidence of ownership of the property
Name of owner(s)

Address of the property

Postcode	

24     Do you have any other assets not already listed on this form?
Do not include personal possessions, furniture, tools of trade etc.	
No
Yes	Give details and attach evidence of the value of each asset
Type of asset 	Value	
No
Yes	Give details and attach evidence of the value of each asset
Type of asset 	Value	

25    Has 100 points been provided for each applicant?
(Please see Housing ACT Fact Sheet - Appyling For Housing)	Applicant 1
No
Yes	Applicant 2
No
Yes	

Assistance with this form	
26    Did either applicant receive assistance to complete this form?	No 	Go to Declaration by applicant(s)  below?
Yes	Which  applicant was assisted?

Applicant 1 	Applicant 2
The person  who helped  will need  to complete  the
Declaration at 27 below	
27     Declaration by person assisting or completing this form on behalf of the applicants(s)	•  I have filled in this form on the basis of the information the applicants(s)  provided me.
•  I have read out the form and the answers to the applicant(s)  who seemed to understand them.
•  I understand  there are penalties  for giving false or misleading information

Signature of person who assisted

Full name

Date	/ 	/	

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Page 4

Please tell us why you are applying  for Social Housing Assistance?

Personal Information  and Privacy Notice

The Community Services Directorate is collecting the information on this form to assess if you can claim social housing assistance.  The collection of this information is authorised by the Housing Assistance Act 2007.

To enable the Community Services Directorate to provide you with coordinated service delivery, you are giving your consent that the information on this form may be used by relevant areas of the Community Services Directorate to facilitate housing assistance.  This includes the provision of associated services required to support and assess your housing assistance including therapy, disability, children, youth and family support.

The Community Services Directorate may also disclose your information to the Health, Education and Training, and Justice and Community Safety Directorates.

If this form requires you to include information about other members of your household, you must seek their consent, or the consent of their guardian, to their information being disclosed as described above.

The information you provide may also be disclosed where authorised or required by ACT or Commonwealth Law.

Your information provided on this form will be stored, used and disclosed in accordance with the requirements of the Privacy Act 1988 (Commonwealth).  You may have access to any information you have provided to ensure that it is accurate, and to allow you to correct if necessary.

Declaration by applicant(s)
I understand:
• the instructions given  on this form and note the Personal  Information and Privacy Notice above;
• this form will be used by Housing ACT to register my application for housing assistance, provided I am eligible  for it;
• that my personal information may be given to community housing providers to provide me with housing assistance;
• that I may become ineligible  for housing assistance if changes occur to any of my, or members of my household’s circumstances, and/or incomes and/or
assets detailed  in this application.

I declare:
• that the information given in this application is complete and correct;
• that I have provided all of the required documents as shown in the Document Checklist.;
• that I have shown the Personal  Information and Privacy Notice above to any member of the household whose personal information is included in this form, or
their guardian.

28    Declaration by applicants(s) Please note that there are legal
penalties for deliberately giving false
or misleading information.

Declaration by applicant(s)

Signature of
Applicant 1

Date	/	/

Signature of
Applicant 2

Date	/ 	/

AF2012-189

Page 5

Consent to exchange and release information

Complete this form if anyone on this Registration to apply for Housing ACT Public Rental Assistance receives support from an agency or organisation and that person allows Housing ACT to contact their support/agency to discuss the registration.
Note: You can revoke your consent at any time by writing to Housing ACT, Locked Bag 3000,  Belconnen ACT 2616.

Applicant  1 	I give permission to Housing ACT for the release and exchange of information about me with the following people or organisations: (you can write more than one name or organisation)

This consent is valid for the period not
exceeding 12 months from: 	/ 	/ 	to	/ 	/

Signature of Applicant or Legal Guardian

Full name

Date	/ 	/

Applicant  2 	I give permission to Housing ACT for the release and exchange of information about me with the following people or organisations:

This consent is valid for the period not
exceeding 12 months from: 	/ 	/ 	to	/ 	/

Signature of Applicant or Legal Guardian

Full name

Date	/ 	/

AF2012-189

Page 6

Consent for Centrelink to provide a Statement of Income

Complete this form if you or any member of your household receives a Centrelink  or Family Assistance  Office payment. Housing ACT will send this form to Centrelink and they will provide a Centrelink Statement  of Income in connection  with this application.
If you need more than one form, contact the Housing ACT Shopfront or print a copy from the website at www.dhcs.act.gov.au

• I authorise  Centrelink to provide to Housing ACT a Centrelink Statement  of Income  in connection with my Registration to apply for Housing ACT Public Rental Assistance.
• I understand  that the Centrelink Statement  of Income will contain:
–  the type and amount  of the pension or allowance payment  Centrelink make to me.
–  the number of dependant  children used to assess any family payments.
–  details  of anything  being  deducted  from my payments  such as Child Support  Agency payments, Centrepay deductions, rent deductions.
–  details of any other income I have told Centrelink about,  such as overseas pensions, child maintenance, returns on investment, wages and salary.
• I understand that these details will be used by Housing ACT to assess my entitlement to Housing ACT Public Rental Assistance.
• I consent to Centrelink providing this Statement  electronically via the Income  Confirmation service. This consent is limited to providing information only in respect of Registration to apply for Housing ACT Public Rental Assistance.
• I understand that I will be able  to obtain  a written copy of the statement  at any time from either Housing ACT or Centrelink.

Applicant 1

Applicant 2

Full Name Centrelink  CRN Signature

Date   	 / 	 / 	

Full Name Centrelink  CRN Signature

Date   	 / 	 / 	

Applicant 3

Applicant 4

Full Name Centrelink  CRN Signature

Date   	 / 	 / 	

Full Name Centrelink  CRN Signature

Date   	 / 	 / 	

AF2012-189

Page 7

Income Statement from Employer

If you have been employed in the last 26 weeks either:
• your employer must complete this form, or
• you can provide payslips for the last 26 weeks.
If you need more than one form, contact Housing ACT or print a copy from the website at www.dhcs.act.gov.au

6 	Has the employee worked any overtime in the last 26 weeks?
No
Yes	Give the  following   details

Weekending	No. of hours of overtime	Payment  for overtime	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	
/	/		$	

1 	Employee’s name

2 	Employee’s present address

Postcode

3 	Name of employing organisation

4 	When did the employee start
work with the organisation?	/ 	/

5 	What  is the gross amount the employee earned in the last 26
weeks (including overtime, 	$
regular allowances and penalties)?

7 	Employer’s details

Name Phone Position Signature

Date	/	/

Company seal or stamp

AF2012-189

Page 8