Application For Almshouse Accommodation General InformationIs there more than one applicant?YesNoIf yes, please add the other applicants name and fill one in form eachName *Preferred Location(s) *BrayBuckleburyDonningtonIffleySection One - About YouTitle *Please SelectMrMrsMsMissOtherPlease specify titleLast Name *First Name *Your Address *Length of time at this address *Previous Address (If less than 3 years)Mobile Number *Your email *Telephone Number *Date of Birth *National Insurance Number *Section Two - About your Current HomeDo you own the home you reside in? *YesNoWhat is the estimated value? *GBPDo you have an outstanding mortgage, if so how much? *GBPWhat are your intentions regarding your current property if you are appointed to an Almshouse? *Do you rent the home you are living in? *YesNoHow much is your monthly rent *GBPWho do you rent from? *Please SelectPrivate landlordFamilySocial HousingDo you share? *Please SelectKitchenBathroomKitchen + BathroomNoneDo you live in a: *Please SelectHouseBungalowFlatMobile homeOtherPlease Specify *Section Three - Health and Social FactorsGeneral Health *GoodFairPoorHearing *GoodFairHearing ImpairedEyesight *GoodFairPoorVisually impairedVision profoundly impairedMobility *GoodFairPoorFrameWalking SticksGrabrails neededWheelchairHandrails NeededDo you have any disabilities? If Yes, Please give brief detailsAre you currently undergoing or awaiting any medical treatment? *YesNoPlease give brief detailsCan you detail any physical or mental disabilities you experience and how they might impact upon your living in our accommodation independently? *YesNoPlease give brief detailsDo you currently have a care package? *YesNoPlease give brief detailsCan you provide details of any significant illness, operations or mental health issues during the last 5 years? *YesNoPlease give brief detailsDo you smoke *YesNoDo you drive? *YesNoIf yes, do you own a car?YesNoHave you ever had a criminal record? *YesNoDo you work? *YesNoIf yes, is this:Full timePart timeVolunteerHave you Applied to any of the following for housing currently? *Social HousingPrivate LandlordNoneSection Four - About Your FamilyNext of Kin DetailsName *Email *Mobile Number *Telephone *Address *Relationship to you *Other relatives or friends who live in or near Berkshire or OxfordshireName *Email *Mobile Number *Telephone *Address *Relationship to you *Have you made a will? *YesNoSection Five - About your IncomeState retirement pension (monthly) *Pension paid by a past employer (monthly) *Private Pension (monthly) *Widow’s or widowers’ pension (monthly) *Total of any other pensions (monthly) *Interest on savings and investments (monthly) *Housing Benefit (monthly) *Pension Credit (monthly) *Attendance Allowance (monthly) *Universal Credit (monthly) *Any other benefits (monthly) *Annuities (monthly) *Bank/Building Society Interest (monthly) *Investments Interest (monthly) *Renting property or land that you own (monthly) *Grants from a charity (monthly) *Financial assistance from friend/relative (monthly) *Financial assistance from a Trust fund (monthly) *Any other income. Please provide detailEmployment or self-employment. Please explain type of employment and hours of work.Section Six - About your CapitalBank Accounts *Building society account *Shares – current value *National saving certificates *Unit Trusts – current value *Premium Bonds – current value *Section Seven - Reasons for wanting to move into Trust accommodationReasons for wanting to move into Trust accommodation *Section Eight – Personal References (Not family)Reference oneTitle 1 *Please SelectMrMrsMsMissOtherPlease specify title *Name 1 *Email Address *Telephone Number 1 *Mobile Phone 1 *Address 1 *Relationship to you 1 *Reference twoTitle 2 *Please SelectMrMrsMsMissOtherPlease specify title *Name 2 *Email Address *Telephone Number 2 *Mobile Phone 2 *Address 2 *Relationship to you if any *Section Nine - Declaration and Medical Consent Form I understand the Hartley Trust conditions of entry which are as follows: Aged 60 years or over (55 or over at Jesus Hospital). Capable of independent living. I do not smoke or have any pets. I declare that the information provided in this application is correct and complete to the best of my knowledge and belief. I understand that the Trust would be entitled to terminate any appointment to an almshouse I may be appointed to as a result of this application if my answers in this application form are untrue, or misleading in any respect (for example, due to omitting or misstating relevant facts). I accept that if I am appointed as a resident, I shall be a beneficiary of the charity and not a tenant. The weekly sum that I pay will be a maintenance contribution and not rent. I confirm that I can look after myself and live independently, with the assistance of family or other agencies if necessary. I consent to my GP or other medical advisor providing the Trust with a medical certificate or report about my health and condition now or at a future date, in accordance with the attached form of authority. I consent to the Trust holding personal and sensitive data relating to me and my personal circumstances under the General Data Protection Regulations (GDPR). I understand that I have the right to request access to the information that is held by the Trust relating to my data. The Trust is obliged to check the immigration status of prospective residents and I have given my National Insurance number on the form as proof of residence. Signed *Date *Consent *Yes, I agree with the privacy policy.Medical Consent FormPlease provide the practice name, GP name, address and telephone number of your GP:Practice Name *GP Name *Address *Telephone *May we approach your GP(s) if medical information is required concerning your suitability for almshouse accommodation? *YesNoPlease note: We can only consider your application if you agree to allow the Trust to approach your GP. We only require information about whether, in the GP’s opinion, you are able to look after yourself independently and, if not, the level of care you require. Our Welfare Officers cannot provide nursing or personal care. It is part of the Trust’s responsibility to ensure that applicants for almshouses are suitably qualified under the terms of the charity’s governing instruments. The Trust, therefore, needs 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 but none will be disclosed for any inappropriate purpose. You may have access to your personal information on request.Please sign to confirm your understanding and consent to the above process. * SubmitPlease do not fill in this field.