This form is to be completed by the tenant. Please complete the form for each person to be added to your household and provide their details.

For each additional person in your household please attach proof of identity, citizenship/ residency or cisa category plus proof of income, property ownership and assets for each additional person over 18.

Main Tenant Details

Main Tenant Name *

Address *

Street address *

City *

State *

Postcode *

Additional Person Details

Date moved in *

Full Name *

Relationship to Tenant *

Gender

Date of Birth *

CRN *

Known by another name?

Yes No

If 'Yes' - Other Name

Email Address

Contact Number

Country of Birth

Ethnic Origin

Aboriginal or Torres Strait Islander?

Yes No

If 'Yes' - Select

Aboriginal Torres Strait IslanderBoth

Other spoken langauges?

Interpreter required?

Yes No

Impairment that affects day-to-day living?

Yes No

If 'Yes', Select:

If 'Other' - Insert below

Do you have any ongoing expenses due to a disability, medical condition or permanent injury enter here:

What Expense

Expense Amount

Frequency Paid

Do you have a different address to the tenant? If so, enter below

Street address

City

State

Postcode

Residential use

Yes No

Commercial Use

Yes No

Value

Amount Owing

Current or former tenant of a social housing provider?

YesNo

If yes, Social Housing Provider?

What is your income before tax?

Income includes pension payments (inc overseas pension), allowances, child support payments, wages, casual earning etc.

Income Type *

Frequency *

Amount *

Attach proof of your income e.g. payslips, centrelink income statement etc.

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What are your money assets?

Assets include interest from the bank, interst from investments etc.

Type of Money Asset

Value of Asset

Attach proof of your assets e.g. bank statements listing the last 4 weeks transactions, any cash, shares or term deposits

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Consent of Additional Person

If the person on the application is AGED 16 YEARS AND OVER they must provide their written persmission for their personal information to be collected by the main applicant. To do this, they need to read the statement below and sign and date this form.

I give my permission for:

my personal information on this form to be collected by the main applicant
the proper use of my personal information by Bridge Housing in order to process this application

Full Name *

Signature *

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Date *

Income Confirmation Scheme Consent Authority

All members of your household who wish to participate in the Centrelink Income Confirmation Scheme should enter their details and signature in the consent table below.

This consent will be used for the sole purpose of authorising Bridge Housing Limited to assess your Centrelink income details, and to use this information for the calculation of your rebated rent.

Note: If you do not want Centrelink to provide your information electronically to Bridge Housing Limited, you will need to obtain the information required from Centrelink yourself and provide it to Bridge Housing Limited.

By signing below:

I authorise Centrelink to electronically provide a statement of information to Bridge Housing Limited to assist in the assessment of my entitlement to services from Bridge Housing Limited.

I understand that the information provided by Centrelink may include, where relevant, current or historical details of payments received, dependants, Centrelink deductions, income, assets and confirmation of my current address.

I understand that this authority, once signed, is effective only for the period I am a customer of Bridge Housing Limited.

I understand that this authority, which is ongoing, can be revoked at any time by giving notice to Bridge Housing Limited.

I understand that I will be able to obtain a written copy of the Statements at any time from either Bridge Housing Limited or Centrelink.

Name of Additional Person *

Date of Birth *

Signature *

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Date *