Application For Housing Assistance Form Page 3
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19Application for Housing Assistance
Please use BLOCK LETTERS and print in black or blue pen only. Please mark all relevant boxes with a
. If you
need more space, please write on a blank page and attach it to the application.
Personal details of main applicant
1.
Your name
Title
Mr, Mrs, Ms, Miss
Attach proof of your
identity. See item 1 on the
Last name
Evidence Requirements
or family name
Information Sheet for
details.
First and middle name(s)
No
Go to 3.
2.
Do you need an interpreter?
Yes
give details
This includes an interpreter for
people who have a hearing
What language?
or speech impairment.
3.
Are you known by another name?
Yes
No
Go to 4.
give details
(for example, previous family name)
What name?
Family Name
First Name
4.
What is your Centrelink Reference
Number?
(if applicable)
5.
Sex
Male
Female
6.
Date of birth
DD/MM/YYYY
Note: If you are under 18 years of age, specific
evidence is required. See the Evidence
Requirements Information Sheet for details.
Unit/House
7.
Residential address
number
Attach proof of NSW
residency or why you need
Street/Avenue
to live in NSW. See item 2
on the Evidence
Requirements Information
Town/Suburb
Postcode
Sheet for details.
7a. Are you staying at the above address?
Yes
No
8.
Contact details
Phone
Mobile
Note: Social housing
providers may use any of the
Email
contact details you provide.
OFFICE
T File number
Client reference number
Application reference number
USE
ONLY
DH3001 04/15
Page 1 of 16
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