Application For Housing Assistance Form Page 8
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1925. Is your current accommodation
Yes
No
Go to 26.
unsuitable, unhealthy or unsafe?
Attach documents that support
Mark the situation(s) which best describes why you think
your answer. See item 14 on the
your accommodation is unsuitable, unhealthy or unsafe.
Evidence Requirements
Information Sheet for details.
It is substandard, dangerous or unhealthy
Without essential facilities (for example no water, electricity,
bathroom or kitchen)
Accommodation aggravates a severe ongoing medical
condition or disability
It is unsafe or unstable for taking a child out of care
It is severely crowded (for example, an adult or couple are
sharing a bedroom with a person aged over three years or there
are more than three children sharing a bedroom or there are
more than two unrelated adults sharing a bedroom)
Immediate family members are forced to live apart
A member of your household is leaving care or a custodial
setting (including a juvenile detention centre, gaol or
community-based order)
Family breakdown
Other
give details
26. Are you seeking housing assistance
Yes
No
Go to 27.
because of violence or risk of harm?
mark all that apply
Attach documents that support your
Domestic violence/family violence
answer. See item 15 on the Evidence
Requirements Information Sheet for
details.
A child in your care is at risk
Threats, violence and/or harassment from another person
27. Do you or anyone on this
Yes
No
Go to 28.
application have a disability or
ongoing medical condition?
Mark all that apply and write the name of the person(s) with
Attach proof. See item 16 on the Evidence
the disability or medical condition.
Requirements Information Sheet for details.
Disability or medical condition
Name of the person(s) with the disability or medical condition
Acquired brain injury
Family Name
First Name
Intellectual disability
Family Name
First Name
Mental illness and/or disorder
Family Name
First Name
Post Traumatic Stress Disorder
Family Name
First Name
Visually impaired
Family Name
First Name
Alcohol and other drug use
Family Name
First Name
Question 27 continues on the next page
DH3001 04/15
Page 6 of 16
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