Version 15.03.04
APPLICATION FORM FOR
HOUSING ASSISTANCE PAYMENT
(HAP Scheme)
OFFALY COUNTY COUNCIL
Áras an Chontae
Charleville Road,
Tullamore,
Co Offaly.
057 93 57439
www.offaly.ie
[email protected]
Reference-
Section A
This section is to be completed by the Applicant
Applicant Checklist
1.
Have completed all parts (1 to 4) of Section A about you and your household.
2.
Have signed the declaration section in Part 5 of Section A
3.
Return a completed Landlord Section B (if this is not being returned directly by the
landlord.)
4.
Attach a copy of any legal custody arrangements that you may have for a member
of your household.
5.
Attach any supporting documents (e.g. 3 recent payslips) regarding income if this
has been requested by your local authority.
Notes
1. If you are applying for Housing Assistance Payment please fill out
Section Aabout yourself and your household (Parts 1 to 5)
and
Section Bmust be filled out by the landlord (Parts 6 to 9)
2. When Section A and B are fully complete please return the form to:
Offaly County Council, Áras an Chontae, Charleville Road, Tullamore, Co Offaly
Tel.: 057 93 57439
3. If you are already on the waiting list for Social Housing Support please write-in your
Local Authority reference number here:
Enter Homeless Pass No. here if applicable:
4. If the members of your household have changed since you made your application
for social housing support, you will need to update your details with the Local
Authority. Depending on the change, this may mean that your housing application
needs be reassessed by the Local Authority.
5. Please note that the Local Authority will only process completed application forms.
Incomplete forms will be returned to the applicant.
Page A-1
Reference-
Section A
Please fill in all of Section A about you and your household
PART 1 - YOUR DETAILS
Please fill in the blank boxes
YOU (APPLICANT)
YOUR SPOUSE/PARTNER
(if applicable)
P.P.S. Number
First Name(s)
Surname
Date of Birth
D
D
M
M
Y
Y
D
D
M
M
Y
Current Address
Phone/Mobile No.
Email address
PART 2 – THE PROPERTY
I am applying for Housing Assistance Payment to be paid on my behalf in relation to the property at
Address of property
Total number of bedrooms in the whole property
If the property is shared, total number of bedrooms available to your
household in the property/part of the property that you rent
Rent for the property is
€
Per (tick)
Month
Week
Are you in receipt of Rent Supplement? (tick)
Yes
No
Is the supplement payment for the property listed above?
Yes
No
Please state the amount of
supplement and total rent
Total Rent paid to
landlord
Page A-2
Amount of
Supplement
€
€
Reference-
Y
PART3– CHILDREN/DEPENDANTS/ANY OTHER HOUSEHOLD MEMBERS
Please complete the table below about any other people in your household that will be living with you,
this may include children and other adults that live with you.
First name
Surname
Date of Birth
Relationship to you
e.g. my son, my sister
Do you have a custody, guardianship or fostering arrangements in
relation to any of the people listed above? (tick one)
PPS Number
Yes
No
If so, please give the name of the person that the custody, guardianship or fostering
arrangementsrelates to and details of the legalarrangement below.
First name
Page A-3
Surname
Details e.g. the nights that the person stays with you.Please attach
a copy of any legal arrangements when returning this form.
Reference-
PART 4 – YOUR HOUSEHOLD INCOME
In the table below, please provide the latest details about your gross income(income before deductions) and the gross income of all the people in your
household. Some members of your household may get income from two or three places, for example, a maintenance payment, a one parent family payment
and some wages. Include each income separately in the table below.Your local authority may ask for supporting documentation to confirm income listed below.
The first entry is an example to assist you in completing the table.
Name of person in
household
John Hughes
Employment Status
Income Type
e.g. employed, unemployed
e.g. wages, maintenance, job
seeker’s allowance
Employed part-time
Wages
Income from
Employment
(€)
€600
Job Seeker’s Allowance
Reference-
How often and when that
amount is paid
e.g. monthly, weekly and day of
payment
Monthly, last Thursday of month
€130
(OFFICE USE ONLY) Total gross household income €
Page A-4
Other
Income
(€)
Weekly on a Thursday
PART 5 – APPLICANT DECLARATION
Please note that the housing authority may ask you to provide additional information or
documents, in order to check the information that you have provided, you will be asked
to get that information back to the local authority within four weeks.
Please read this declaration carefully and sign and date it when you are satisfied that you
understand it.
Please note that an application for Housing Assistance Payment will only be accepted
when this application form has been completed and this declaration has been signed.
Collection and Use of Data:
The housing authority will use the data which you have supplied to assess and administer your application for
Housing Assistance Payment. Your data will be also be processed by a central administrative body involved in
administrating the Housing Assistance Payment scheme. Data may be also shared with other public bodies for
the purpose of the prevention or detection of fraud. The localauthority may, in conjunction with the Department
of the Environment, Community & Local Government, process this data for research purposes, including
forward planning in relation to the assessment of housing needs.
The housing authority may (for the purpose of its functions under the Housing Acts 1966 – 2014) request and
obtain information from another housing authority, the Criminal Assets Bureau, An Garda Siochána, the
Minister for Social Protection, the Health Service Executive (HSE), or an approved housing body in relation to
occupants or prospective occupants of, or applicants for, local authority housing. The housing authority may
also, in the exercise of their housing functions, request and obtain information about any person that the
authority considers may be engaged in anti-social behaviour.
Declaration:





I/We declare that the information and particulars given by me/us on this application are true and correct.
I/We undertake to notify the housing authority of any change in my/our household circumstances (e.g.
address, household composition, employment etc.).
I/We also authorise the housing authority to make whatever enquiries it considers necessary to verify
details of my/our application.
I/We am/are aware that the furnishing of false or misleading information is an offence liable to prosecution.
I/We confirm that I/we understand and accept that if my/our Housing Assistance Payment application is
approved and payments commence to my/our landlord that my/our housing needs will be met and that I/we
will be removed from the Local Authority’s housing list.
Signed (Applicant):
_________________________________ Date: _____________________
Signed (Spouse/Partner):
_________________________________ Date: _____________________
OFFICIAL USE ONLY
Date valid application received
_______________________________
Decision date
_______________________________
Details:
__________________________________________________________________________
______________________________________________________________________________________
Page A-5
Reference-
Section B– Landlord
This section is to be completed by the Landlord
Landlord Application Information Check List
When returning this form to your local authority you will need to:
1. Have completed all parts (6 and 7) of Section B about you and the property.
2. Have signed the declaration section in Part 9 of Section B.
3.
Attach a copy of your valid Tax Clearance Certificate if this is available. If a
valid Certificate is not available one must be provided to the local authority
within 5 months of HAP payments commencing.
4.
Attach a header from a Bank Statement, with the landlord/agent name and
address to prove that the the named person/company nominated to receive
HAP payments is the account holder for the bank details provided.
5.
Attach proof of ownership of the property with the landlord/agent name and
property address in one of the following forms. Please see Terms and
Conditions point 2 page B-4 for more details:
a.
title deed or similar legal instrument proving ownership of the property
b.
evidence of current registration with the PRTB
c.
evidence of current paid buildings insurance policy/schedule
d.
evidence of payment of Local Property Tax (LPT)
e.
mortgage statement dated within the last 12 months
s
s
s
If Section B is returned separately by the landlord please return to:
Offaly County Council, Áras an Chontae, Charleville Road, Tullamore, Co Offaly
Tel.: 057 93 57439 Email: [email protected]
Page B-1
Reference-
Section B- Landlord
Please fill in all of Section B, unless indicated otherwise.
PART 6 – LANDLORD AND BANK DETAILS
P.P.S Number
Tax reference no.
(for individual)
(For body corporate)
First Name
Surname
Landlord
Address
Phone
Email
Nominated Agent details (if applicable)
Agent Name
Agent Address
Agent phone
Agent
email
Bank details for payment (Please submit header of a Bank Statement to prove that the named
person/company is the account holder)
Name of
Account Holder
Bank name
& address
BIC
IBAN
Tax Compliance
Do you hold a valid Tax Clearance Certificate?
Yes
No
(tick)(Please attach a copy of the certificate)
Certificate number (write in)
If you do not hold a valid Tax Clearance Certificate, please confirm that
you will obtain the certificate and send it to the local authority in the next
five months (tick one). A valid Tax Clearance Certificate must be submitted
annually.
Page B-2
Yes
No
Reference-
PART 7 – PROPERTY DETAILS
(please fill out in relation to the property the prospective HAP Tenant will reside in)
It is proposed to let the property at:
To(tenant(s) names):
Tick the box which best describes the property
House
which is (tick one): detached
semi-detached
terraced
Maisonette/ Duplex
Apartment/Flat
Studio Flat
Yes
No
Is the accommodation self-contained?
i.e. there are no other households living in the same property (tick one)
If the accommodation is not self-contained, please indicate how many people live in
the whole property excluding applicant household (write in)
How many bedrooms are there available to this household?
(not including bedrooms let to other tenants) (write in)
What is the rent for the property for this household?
(This must be the same rent as per
the tenancy agreement/rent book)
€
Rent Limits are available from the Local Authority
Yes
Is/will there be a tenancy agreement and/or rent book
No
in relation to this property?
Rent is due (tick one)
Is the property furnished or unfurnished?(tick one)
Weekly
Calendar monthly
Furnished
Unfurnished
Please note that the commencement of HAP payments is subject to local authority approval
For new tenants, what is the proposed tenancy start date?
D
D
M
M
Y
Y
(write in DD/MM/YY)
OR
For existing tenants, what is the date that the tenant moved in
D
D
M
M
Y
Y
Date rent is paid up to (if applicable) (write in DD/MM/YY)
D
D
M
M
Y
Y
Date for the end of the tenancy (if applicable) (write in DD/MM/YY)
D
D
M
M
Y
Y
to the property? (write in DD/MM/YY)
Deposit for the property
€
(write in amount)
Deposit has beenpaid
Yes
No
(tick one)
Local Property Tax Property ID number (write in)
Page B-3
Reference-
PART 8 – TERMS AND CONDITIONS
Payment of the Housing Assistance Payment (HAP) to a landlord is subject to the following terms and
conditions:
1. Tenancy: The applicant HAP tenant must have a valid tenancy in the property the subject of the HAP
payment.
2. Ownership of the property the subject of the HAP payment: the landlord must provide proof of
ownership of the property in one of the following forms (a photocopy is acceptable) a)title deed or
similar legal instrument proving ownership of the property; b)evidence of current registration with the
PRTB showing the landlords name and property address;c) evidence of current paid buildings
insurance policy/schedule for the property (renewal notices will not be accepted);d) evidence of
payment of Local Property Tax (LPT)which should include the name of the landlord, address of the
property and be dated within the last 12 months or e)mortgage statement, indicating the landlord as
the owner of the property and indicating the address of the rental property, and dated within the last
12 months.Proof of ownership is required irrespective of whether the landlord is receiving HAP
payments directly or if payments are received by a nominated managing agent.
3. Rental Accommodation Standards: the property provided by the landlord to the tenant must comply
with the Housing (Standards for Rented Houses) Regulations 2008 as amended. Further information
regarding these standards can be found on the housing section of the Department of the Environment,
Community and Local Government website www.environ.ie. The local authority will carry out an
inspection of the property within 8 months of commencing HAP payments to ensure that the property
is in compliance. If this inspection identifies matters of non-compliance with the standards, the
landlord will be obliged to remedy the matter(s) of non-compliance within a time period indicated by
the local authority in written notice to the landlord. Failure to remedy any matters of non-compliance
within the stated timeframe will result in the suspension or cessation of HAP payments.
4. Tax compliance: to be eligible to receive HAP payments, landlords must demonstrate their compliance
with all relevant tax obligations by producing a valid Tax Clearance Certificate. A valid Tax Clearance
Certificate should be returned with this form. If a valid certificate is not available landlords will have up
to 5 months following commencement of HAP payments to produce a valid Tax Clearance Certificate
for the local authority.However, if within the 5 months, a further payment by the authority falls due
which, if paid would result in total payments by the authority to the landlord in any period of 12 months
exceeding €10,000, that payment will not be made without the landlord providing a valid Tax
Clearance Certificate. The landlord will be obliged to produce renewed Tax Clearance Certificates at
the expiration of the previous Certificate as requested by the local authority.
5. Payments: HAP payments will be made on a monthly basisin arrears by electronic funds transfer to a
nominated bank account. Payments may be made directly by the local authority or by a designated
third party on behalf of the local authority. Payment by a local authority to a landlord or his or her
agent does not imply any liability on the part of the local authority for rent due to the landlord. This
arrangement does not establish any partnership, any joint ventureor landlord and tenant relationship
between the landlord and the local authority.
6. Deposits: the local authority is not liable for the payment of deposits in respect of a property the
subject of HAP payments.
7. Tenant rental contribution to local authority:HAP tenants will be required to pay a weekly rental
contribution to the local authority. Payment of this contribution is a condition for the continued eligibility
of the tenant to benefit from the local authority making HAP payments, on their behalf to the landlord.
Non-payment of this rental contribution may result in suspension or cessation of HAP payments to the
landlord.
8. Management of the tenancy: management of a tenancy in respect of which HAP payments are made
is the sole responsibility of the landlord in accordance with the Residential Tenancies Act 2004.
Avoidance of anti-social behaviouris a condition for the continued eligibility of the tenant to benefit
from the local authority making HAP payments, on their behalf to the landlord. The local authority may
suspend or cease HAP payments to the landlord if the tenant engages in anti-social behaviour.
Page B-4
Reference-
PART 9 - LANDLORD DECLARATION
Please ensure that you have read the Terms and Conditions set out in Part 8 in full before completing
the Declaration at the end of Part 9.
I confirm I have read theTerms and Conditions which set out the statutory requirements and I am aware of
my obligations in this regard.
1) Statement on Ownership
I certify that I am the full and absolute owner of the property detailed above under Part 7 (the “Property”)
2) Tax Compliance
I am fully aware that I must produce a valid Tax Clearance Certificateto the local authority to receive HAP
payments. I am fully aware that if I cannot return a valid Tax Clearance Certificate with this form that I will
have a maximum of 5 months following commencement of HAP payments to produce a valid Certificate to
the Local Authority.
3) Standards for Rented Houses
I certify that the Property is in such a lettable condition that meets the following statutory requirements for
rented accommodation:
 Housing (Standards for Rented Houses) Regulations 2008, &
 Housing (Standards for Rented Houses)(Amendments) Regulations 2009.
I acknowledge and agree that Offaly Council (the “Local Authority”) will carry out an inspection in due
course at the above property to ensure the property meets the standards as stated above.
I am fully aware that the Local Authority will be making Housing Assistance Payments in respect of the rent
due for the tenancy of the Property solely on behalf of the tenant and notwithstanding the receipt of the
Housing Assistance Payments, I acknowledge and accept that the payment by the Local Authority under the
Housing Assistance Payments is strictly on behalf of the tenant of the Property and that this arrangement
shall not establish any contractual arrangement, any partnership, any joint venture or any landlord and
tenant relationship between with the Local Authority and I.
Lastly, I hereby further represent and warrant to the Local Authority and acknowledge and agree that I have
had the opportunity to seek and have not been prevented from seeking independent legal advice prior to the
signing of this declaration. In the event that I do not obtain independent legal advice prior to signing this
declaration I did so voluntarily without undue pressure and I agree that my decision not to obtain
independent legal advice shall not effect in any way the validity and enforceability of my obligations
hereunder.
Collection and Use of Data:
The housing authority will use the data which you have supplied to administer the application for Housing
Assistance Payment. Your data will be also be processed by a central administrative body involved in
administrating the Housing Assistance Payment scheme. Data may be also shared with other public bodies for
the purpose of the prevention or detection of fraud. The localauthority may, in conjunction with the Department
of the Environment, Community & Local Government, process this data for research purposes.
Signed
Print Name
Date
Page B-5
Reference-