Title *
Please Select
Mr
Mrs
Miss
Ms
Dr
Exor
Mstr
Rev
Other
First Name *
Surname *
Date of Birth *
Previous Surname (if applicable)
National Insurance Number *
Current Address *
When did your tenancy start?
Landline Phone Number
Mobile Number
Email Address
Are you or anyone who will live with you related to a Barnsley Council Councillor or an employee of Berneslai Homes or Barnsley Council?
Please Select
Yes
No
Give details
Are you a joint tenant?
Please Select
Yes
No
Title *
Please Select
Mr
Mrs
Miss
Ms
Dr
Exor
Mstr
Rev
Other
First Name *
Last Name *
Date of Birth *
National Insurance Number *
Which best describes the type of property you live in
Please Select
House
Upper flat
Lower flat
Bungalow
Maisonette
Bedsit
How many bedrooms are in the property
Please Select
Bedsit
1
2
3
4
5 or more
What type of heating do you have
Please Select
Gas
Solid fuel
Electric
District heating
Air Source
What bathroom facilities does the property have?
Bath
Shower over the bath
Level Access Shower (Wet Room)
Half Cubicle Shower
A Level-Base Shower
Does the property have any of the following adaptations or special features (Please tick all that apply) *
A level-base shower
Handrails
Ramps
Stairlift
Through Floor Lift
None of these
Are you a Berneslai Homes tenant
Please Select
Yes
No
Who is your landlord
Their Address
Their phone number
Please give details of the people who live with you at your present address and will be moving with you.
Are you or anyone who will move with you pregnant?
Please Select
Yes
No
Who is pregnant?
When is the baby due?
Does anyone in your household get professional support?
Please Select
Yes
No
Who do they get support from?
Social worker
Mental health worker
Probation Officer
Other
Please give the names and contact details of the people giving support
Have you or anyone living with you, been convicted of the following offences?
Using or possessing drugs
Please Select
Yes
No
Person’s full name
Date of conviction
Sentence
Supplying drugs
Please Select
Yes
No
Sentence
Person’s full name
Date of conviction
Theft or damage to our property or property owned by a landlord
Please Select
Yes
No
Person’s full name
Date of conviction
Sentence
Burglary or theft from homes, motor vehicles and so on
Please Select
Yes
No
Person’s full name
Date of conviction
Sentence
Racial harassment
Please Select
Yes
No
Person’s full name
Date of conviction
Sentence
Sexual harassment or sex discrimation
Please Select
Yes
No
Person’s full name
Date of conviction
Sentence
Assault (verbal or physical)
Please Select
Yes
No
Person’s full name
Date of conviction
Sentence
Intimidating or harassing neighbours, other residents or employees *
Please Select
Yes
No
Person’s full name
Date of conviction
Sentence
Being evicted from a rented home for not paying rent
Please Select
Yes
No
Person’s full name
Date of conviction
Sentence
Being evicted from a rented home for causing a nuisance
Please Select
Yes
No
Person’s full name
Date of conviction
Sentence
Antisocial behaviour
Please Select
Yes
No
Person’s full name
Date of conviction
Sentence
Any other convictions (apart from minor traffic offences)
Please Select
Yes
No
Person’s full name
Date of conviction
Sentence
Why do you want to exchange? (You can tick up to three reasons)*
Current home is too small
Current home is too large
Moving to give or receive support
Problems with neighbours
Racial harassment
Cannot afford current rent
Health reasons
Moving for work
Other
If other please give further details below:
Please tell us the full name of the person you want to exchange with
Title *
Please Select
Mr
Mrs
Miss
Ms
Dr
Exor
Mstr
Rev
Other
First Name *
Last Name *
Their address
Their phone number
Did you use House Exchange to find this exchange?
Please Select
No
Yes
How did you find this exchange?
How do you want us to contact you to arrange to inspect your current home?
Please Select
Text message
Phone (Landline)
Mobile Phone
Email
Is there anything we can do to make things easier when we contact you? (For example – if you have difficulties with your hearing, sight or speech)?
Please Select
Yes
No
Please give details
Which language do you prefer to use?
Please Select
English
Other
If so, which language?
By completing this form you acknowledge that we will follow our responsibilities under data protection legislation. We will store the information securely, share it with partners and other statutory agencies where we have the right under law to do this, use it only for the purpose it was provided and process it as set out in our privacy policy. For more information please see our privacy policy on our website
By ticking the box at the bottom of this section I declare that I fully understand and agree with the following statements:
• I declare that the information I have given on this form is correct and that you may contact me if you need to discuss the matter further.
• I understand that if you later find that I have deliberately supplied false information or omitted to supply information, we may take action.
• I understand that if I have not completed this form fully it may result in a delay in us acting on your request.
• I understand you may share my information with other agencies to detect and prevent fraud.
• If the exchange is approved, the property I move into will be my only and permanent home.
• I give permission to you to contact my existing and previous landlords for details about any tenancies I have held and for my landlord or former landlord to disclose that information to Berneslai Homes.
• I give you my permission and understand that you may need to get information from other organisations for the purpose of checking this application. These include but are not limited to the probation Services, health authority, social services, education services, housing services, the Police, courts and other local directorates.
I confirm