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DH3015 - Change of Circumstances - Applications

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					                                    Change of
                            Circumstance - Applications
                                  Please print in BLOCK LETTERS with a black or blue pen

This form is to be completed by applicants (including approved transfer applicants) to advise a social housing provider of
any changes to their circumstances (i.e. change in income, adding or removing a person to an application, change of
locational preference, confirmation of Aboriginality, change in support needs, etc). For information or assistance with this
form, phone 1300 Housing 24 hours a day, seven days a week. Please mark relevant boxes with a            If you need more
room to answer any question, please include details on a separate page and attach it to this form.

       T File number                                      Client reference number               Application reference number



Applicant details                              Title
                                  Mr, Mrs, Ms, Miss
                           Last name or family name

                                    Given name (s)

                                       Date of birth         DD / MM / YYYY

What has changed?                                      (Tick only the boxes that indicate what has changed and provide the
                                                       details and or evidence where required)
1. Change of name
   Attach proof of the               Previous name
   name change
   (i.e. Deed Poll,
   Change of Name                        New name
   Certificate, Marriage
   Certificate)                  Reason for change
                                     (i.e. marriage)


2. Change of address

New address                      Unit/House number                Street/Avenue

                                      Town/Suburb                                                 Postcode

3. Change of contact details

                                             Phone                                     Mobile

                                              Email


4. Change of residency status/visa category
    Attach proof of
    residency status/visa      New residency status
    category and number.
    See the Evidence          Visa/subclass number
    Requirements
    Information Sheet for
    more information.



DH3015 04/10                                                                                                         Page 1 of 6
5. Change in income                                             Complete the table below
   Attach proof of Income.
   See the Evidence Requirements Information
   Sheet for more information.

                                                                     Type of income
  Name of person whose income has changed                                                           Weekly income before tax
                                                                  (i.e. wage, pension)
                                                                                                $
                                                                                                $
                                                                                                $


6. Change in assets
   Attach proof of money assets
   See the Evidence Requirements Information
   Sheet for more information.


                                                                      Type of asset
  Name of person whose assets have changed                                                               Value of assets
                                                                   (i.e. cash, shares)
                                                                                                $
                                                                                                $
                                                                                                $


7. Change in property ownership
     Attach proof of property ownership
     See the Evidence Requirements Information
     Sheet for more information.

Note: If you part own property or land, list the names of
      the other owners as well as your own.
                                                                                      Is the property
                                                                                                          If you own the property
                                                                                        or land used
                                                                                                             with someone else,
      Name of owner(s)                     Address of property or land                 for residential
                                                                                                            what is your share in
                                                                                      or commercial
                                                                                                         the property (e.g. 50%)?
                                                                                         purposes?
                                                                                  $
                                                                                  $
                                                                                  $

            Total value of all property/land owned          $

                      Amount owing (if mortgaged)           $


8. Change in medical condition / disability
   Attach proof of disability or medical condition.
    See the Evidence Requirements Information Sheet           Name of medical              Name of person/s with the medical
   for more information.                                    condition or disability             condition or disability

Tick all that apply and write the name of the
person/s with the disability or medical condition




DH3015 04/10                                                                                                               Page 2 of 6
9. Do you want to add a person/s
   to your application?

9 a. Are you a social housing applicant                Social housing applicant   Approved transfer applicant
     or approved transfer applicant?

    Note: A social housing applicant is a person       Complete an                Complete an
    applying for public housing, community             Additional Person          Additional Person
    housing or Aboriginal Housing                      Information form           Information form
    Note: An approved transfer applicant is a tenant
    who is living in a social housing property and
    has been approved for transfer


10.Do you want to remove a person/s from
   your application?

                                                       Social housing applicant   Approved transfer applicant
10 a. Are you a social housing applicant or
     approved transfer applicant?                      Provide details below      Provide details below

    Note: A social housing applicant is a person
    applying for public housing, community
    housing or Aboriginal Housing
    Note: An approved transfer applicant is a tenant
    who is living in a social housing property and
    has been approved for transfer


 Full name of each person to be removed from                                        Date person is to
                                                             Date of birth
               your application                                                       be removed

                                                          DD / MM / YYYY               DD / MM / YYYY
                                                          DD / MM / YYYY               DD / MM / YYYY
                                                          DD / MM / YYYY               DD / MM / YYYY


                                            Reason


11. Confirmation of Aboriginality or Torres
   Straight Islander origin
    Attach documents that support your answer.
    See the Evidence Requirements Information
    Sheet for more information.
11 a. Do you want to be considered for an              Yes                        No
      Aboriginal Housing Office property?



12.A person in the household has a
   financial management order

   We may obtain a copy of the order from
   the organisation
            Full name of person with a                                            Contact phone number
                                                       Name of organisation
           financial management order                                                of organisation




DH3015 04/10                                                                                              Page 3 of 6
13.A person in the household has a
   guardian (public or private)
   Attach documents that support your answer.
   See the Evidence Requirements Information
   Sheet for more information.

                                                    Name of organisation/person           Contact phone number
    Full name of person who has a guardian
                                                       who is the guardian                of organisation/person




14.Change of support program
    Attach documents that support your answer.
    See the Evidence Requirements Information
    Sheet for more information.

                                                    Name of organisation/program          Contact phone number
     Full name of person receiving support
                                                         providing support                 of support provider




15.Change of type of social
   housing preferred
                                                      All available social housing options (this includes public housing
    Note: if you have been approved                   and Aboriginal Housing Office properties provided by Housing
    for priority housing you may be                   NSW and community housing provided by registered community
    offered accommodation by any social               housing providers)
    housing provider
                                                      Public housing and Aboriginal Housing Office properties only
                                                      (this is social housing provided by Housing NSW)
                                                      Community housing only
                                                      (this is social housing provided by registered community housing
                                                      providers only)
16.Change of current housing situation
   (i.e. Need to move out because you
   received a Notice of Termination, your
   current accommodation is unsuitable,
   unhealthy or unsafe)

   Attach documents about your current housing
   situation. See the Evidence Requirement
   information Sheet for more information.

17. Change of locational preference

                                     Area or Town
Note: While social housing providers will try to
match people to their preferred area,
specific locations cannot be guaranteed.
Some areas have longer waiting times than others.

18. Details of any other changes not already
   covered in this form
   (i.e. Domestic violence, family break - up,
   carer requirements, etc)
                                   Please specify




DH3015 04/10                                                                                                     Page 4 of 6
Notice and Declarations
Under the Housing Act 2001, the Privacy and Personal Information Protection Act 1998 and the Health Records and
Information Privacy Act 2002, you must be told why your personal information (including health information) is being
collected, how it will be used and whether it will be given to or exchanged with another party.

Under the Housing Act 2001 a fine of up to $2,200 and/or three months imprisonment applies for making a false
statement or representation. Anyone who wilfully makes any false statements that result in them obtaining
accommodation or other financial benefit of any kind may be refused further assistance by housing providers
or prosecuted.

Notice: Your personal information and any relevant health information provided on this form will be exchanged between
social housing providers (public, community and Aboriginal housing) for the purpose of processing your application.

Declaration                                        • I understand the instructions given on this form.
                                                   • To the best of my knowledge, the information provided in this
                                                     form is correct.
                                                   • I understand there are penalties for giving false or
                                                     misleading information.


                       Full name (please print)


                                      Signature


                                         Date           DD / MM / YYYY


Is another person helping you to fill out this          Yes                                  No
form?
                                                        If yes, that person should read
                                                        and sign the declaration below.
Declaration from person assisting or completing this application on behalf of the applicant

                                                   • I filled in this form on the basis of the information the applicant
                                                     gave me.
                                                   • I have read out the form and the answers to the applicant who
                                                     seemed to understand them.
                                                   • I understand there are penalties for giving false or
                                                     misleading information.

                        Full name (please print)

                                      Signature


                                         Date           DD / MM / YYYY
                         Contact phone number




DH3015 04/10                                                                                                        Page 5 of 6
                                                           Office Use Only

     Name of social housing provider

     Received date:                                            DD / MM / YYYY

     Place the form and supporting documents in the            DD / MM / YYYY
     client’s digital client container



     Is the form complete and all supporting                   Yes   • Send the                  No    Send the letter
     document provided?                                                Acknowledgement                 requesting information
                                                                       letter and
                                                                     • Complete the
                                                                       Change of Circumstances
                                                                       Assessment form



     Date Acknowledgement letter sent                          DD / MM / YYYY

     Date letter requesting information sent                   DD / MM / YYYY


     Has the requested information been                        Yes     Complete the              No   • Record in TRIM
     provided within the timeframe?                                    Change of                      • Send the
                                                                       Circumstances                   second letter
                                                                       Assessment form                 requesting information




     Has the requested information been                        Yes     Complete the              No   • Record in TRIM, and
     provided after the second request?                                Change of                      • Take appropriate
                                                                       Circumstances                   actions to
                                                                       Assessment form                 close the application




                  Name of the officer (please print)

                                                Position


                                               Signature


                                                   Date         DD / MM / YYYY




DH3015 04/10                                                                                                         Page 6 of 6

				
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