Internal transfer form - Moat

Anti-social behaviourHave you or has anyone living with you or visiting you, including children, ever carriedout any acts of either harassment, nuisance or anti-social behaviour?Has Moat, as your landlord, ever written to you or spoken to you about your behaviour,or the behaviour of anyone living with you or visiting you, including children?Has your behaviour caused a nuisance or annoyance to others or have you broken theterms of your tenancy agreement in some other way?Have you or anyone in your household ever been a victim of harrassment, nuisance oranti-social behaviour?YesYesYesYesNoNoNoNoIf you have answered yes to any of the above question please let us know when this was and give all the relevant details.PetsDo you have any pets? Yes NoIf yes, please give details of the number of animals and breeds of dogs, if you have themPets may be allowed by prior arrangement.About your householdPlease give details of everyone living with you at present on a full time basis, including yourself.Forename Surname Sex Date of birth Age Relationship to you Date moved inYOU

Do you have anyone who lives with you on a part time basis? If yes, please give the following details:NameHow oftendo theylive with you?At what other address to they live?Reason they do not live with you all thetime? (E.g shared custody, student etc.)PregnancyIs there anyone on your application who is pregnant?YesNoIf yes, what is the name of the pregnant mother and when is the baby is due?Name of pregnant mother isDate baby dueAll about where you liveWhich of the following best describes your current home?House Bungalow Flat Maisonette BedsitIf you live in a flat, please state floor level:Is there a lift in the property?Do you have stairs inside your home?How many single bedrooms do you have?How many double bedrooms do you have?How many living rooms do you have? (not including the kitchen, downstairs toilet or hall)Is your property adapted for disabled use? If so, please give details:OneTwoWhat type of central heating do you have?Full Partial NoneFull gas Warm air Storage heatersSolid fuel Oil OtherWhat type of garden do you have?Own private garden Shared garden No gardenHave you or your partner ever had another tenancy with Moat or Bourne?If yes, what was the address?YesNoWhen did the tenancy end?Were you evicted?YesNoWhat type of tenancy do you now have?Secure/Fair Assured Assured shortholdProbationary Starter Don’t know

All about your incomeIn order to see if you will be able to manage with affordable housing rents higher than your current rent and to help us toidentify if you may need extra support or assistance we would like to know the income if your household.Your detailsDetails of your partner orjoint tenant (if applicable)Are you working?Yes No Yes NoIf yes, please provide the name and addressof your employerWhat is your job title?Gross income (before tax and other deductions)per weekper monthper weekper monthDo you receive housing benefit?Yes No Yes NoDo you receive incapacity benefit?YesNoYesNoDo you receive severe disablement allowance?YesNoYesNoDo you receive disability living allowance?YesNoYesNoDo you receive disabled persons tax credit?YesNoYesNoDo you receive carers allowance?YesNoYesNoDo you receive attendance allowance?YesNoYesNoDo you receive child benefit?YesNoYesNoAre you retired?Do you receive a state pension?Are you a student?If yes, are you a full time or part time student?Yes No Yes NoYes No Yes NoYes No Yes NoFull time Part time Full time Part timeDo you receive an income from any other source?If yes, please give details from where you receive thisincome and how much.Yes No Yes No

Why you want to movePlease explain why you want to move (except for medical reasons). Please list all the circumstances that you would like tobe taken into consideration. Continue over the page if necessary.

Why you want to move (continued)