Mutual Exchange online form

Title ( required )

Mr

Mrs

Ms

Miss

Please enter below

First name(s) ( required )

Surname ( required )

Present address and postcode ( required )

Title ( required )

Mr

Mrs

Ms

Miss

Please enter below

First name(s) ( required )

Surname ( required )

Present address and postcode

Title ( required )

Mr

Mrs

Ms

Miss

Please enter below

First name(s) ( required )

Surname ( required )

Date of birth ( required )

National Insurance Number

Mobile

Home

Email

Current landlord details - Landlord name ( required )

Landlord's address and postcode ( required )

landlord's phone number ( required )

Tenancy start date ( required )

Title

Mr

Mrs

Ms

Miss

First name(s)

Surname

Date of birth

National Insurance Number

Mobile

Home

Email

Title

Mr

Mrs

Ms

Miss

Please enter below

First name

Surname

Address and postcode

Mobile

Email

relationship to you (e.g your son, support worker or friend)

What type of support do they give you?

Person 1 - First name

Person 1 - Surname

Person 1 - Gender

Male

Female

Please enter below

Person 1 - Date of birth

Person 1 - Their relationship to you

For all children under 16, who is the child benefit paid to?

Is this the main residence for all children listed?

Yes

No

Please enter below

Person 2 - First name

Person 2 - Surname

Person 2 - Gender

Male

female

Please enter below

Person 2 - Date of birth

Person 2 - Their relationship to you

Person 3 - First name

Person 3 - Surname

Person 3 - Gender

Male

Female

Please enter below

Person 3 - Date of birth

Person 3 - Their relationship to you

Person 4 - First name

Person 4 - Surname

Person 4 - Gender

Male

Female

Please enter below

Person 4 - Date of birth

Person 4 - Their relationship to you

Person 1 - First name

Person 1 - Surname

Person 1 - Gender

Male

Female

Person 1 - Date of birth

Person 1 - Their relationship to you

For all children under 16, who is the child benefit paid to?

Is this the main residence for all children listed?

Yes

No

Please enter below

Are you a registered foster carer?

Yes

No

Please enter below

Do you have any pets to take with you?

Yes

No

Please enter below

If yes, please give details.

Person 2 - First name

Person 2 - Surname

Person 3 - Gender

Male

Female

Person 2 - Date of birth

Person 2 - Their relationship to you

Person 3 - First name

Person 3 - Surname

Person 3 - Gender

Male

Female

Person 3 - Date of birth

Person 3 - Their relationship to you

Person 4 - First name

Person 4 - Surname

Person 4 - Gender

Male

Female

Person 4 - Date of birth

Person 4 - Their relationship to you

Number of bedrooms in the property

Number of bedrooms used

On which floor do you live?

Please enter below

have you or a member of your household previously had a tenancy with Williamsburgh? If yes, please give details of the name, address and dates of tenancy

Has your landlord served a notice of proceedings on you?

Yes

No

Please enter below

If yes, when and what for

Has your landlord obtained a court order against you?

Yes

No

Please enter below

If yes, when and what for

Do you or anyone who will be living with you consider themselves to have a disability?

Yes

No

Please enter below

Please select

Uses a wheelchair Household member effected (name please)

Has problems getting around but does not use a wheelchair

Is blind or has sight problems

Is deaf or has hearing problems

Cannot speak or has difficulty with speech

Has a learning difficulty

Has mental health problems

Long-term health problems

Other reason

If any of the above contributes to the reasons you wish to be re-housed, please provide details below

Do you require any special adaptations to your property?

Yes

No

Please enter below

Please tell us why you wish to mutually exchange your home

Property too small

Property too large/under occupying

Property unsuitable because of ill health/disability

Cannot afford the rent

To move nearer to family/friends

To move nearer to work/education facilities

Other

Did you or any of the persons applying with you come into the UK during the last five years?

Yes

No

Please enter below

Are you or any of the persons applying with you subject to any immigrations controls?

Yes

No

Please enter below

Are you or the persons applying with you Asylum Seekers?

Yes

No

Please enter below

Have you or the joint applicant, currently or in the past 12 months been; Employed by Williamsburgh

Yes

No

Please enter below

a Board Member of Williamsburgh?

Yes

No

Please enter below

If yes to any of the above, please give details below

By signing this form you are confirming that:
1. You understand that the information supplied on this form will be used to process your application for housing. As part of your application for housing, you understand that it may be
necessary for us to request information from a previous or current landlord, mortgage lenders, local government departments, social workers, probation officers or the police. You hereby
authorise and agree to us contacting any of the above to obtain such information as we feel is necessary.
2. The European General Data Protection Regulation and the Data Protection Act 2018 came into force in May 2018. This required some changes in how data is managed but also provides
additional rights for you as an individual.
3. The details given in this application are true. You understand that if you have knowingly or recklessly given false information, or withheld information in connection with this application, your home may be repossessed.

You - Please sign and date the form

Joint tenant - Please sign and date the form

If this form has been filled in by someone other than the person(s) making the application.
Please tell us why you are filling in this form for the applicant.
I declare that as far as possible, I have confirmed with the person(s) applying that the answers I have written on this form are correct.
Signature
Name and Date
Relationship to the applicant(s)

Mutual Exchange

Both you and your mutual exchange partner need to complete a seperate form each.