Application No.

Housing assistance application

pursuant to the Housing Act 2003

Application for Social Housing

A range of housing assistance options are available to help Queenslanders with their housing needs.
Options include private housing products, public housing, community housing, Aboriginal and Torres Strait
Islander housing and referrals to support services.

This application collects essential information to assess eligibility for the Public Housing, Community
Housing, Aboriginal and Torres Strait Islander Housing and Indigenous Council Housing Programs.

Important information

Your eligibility for housing assistance will be assessed based on the information and the supporting
documentation you provide with this application.

If your circumstances change at any time, please notify your local Housing Service Centre
within 28 days of the changes.

Completing this application – have you:

Answered all the questions with a tick where there are Yes/No boxes?

Collected supporting evidence including proof of income and assets for each household
member listed on this application?

Read and signed the declaration and consent on the last page?

Had this application signed by a witness on the last page?

A Housing Service Centre officer can witness this application if you are submitting it in person.

Got your identification ready for when you submit this application?
Alternatively, you can attach witnessed copies of your identification evidence if you are returning this
application via post.

For more information on housing assistance, please call or visit your local Housing Service Centre.
Alternatively, you can access information at www.qld.gov.au/housing or download our ‘Housing
Assist Qld’ mobile app from the Google Play, Microsoft or Apple App stores.
 Application for Social Housing

Application Assistance
What is your first spoken language?

Do you need an interpreter? If you speak in a language other than English, or have hearing difficulties, we can
arrange for an interpreter to assist you.

Which interpreter do you require? Language, provide details:

Signing

Do you need assistance when

making decisions? Yes No
This may be a person that helps you to If yes, which of the following.
make decisions, or someone who makes
decisions on your behalf about your Public Trustee Family, Friend or Advocate
personal, lifestyle or financial matters.
Office of the Public Guardian Power of Attorney
Other, provide details:

What type of housing would Social housing – Housing in remote Aboriginal

you like to apply for? Public housing and and Torres Strait Islander
community housing communities
Tick all that apply.

Household Contact Details

Full name:

Preferred contact method? Email Letter Telephone SMS

Tick all that apply.

Current address:

Mailing address: As above

If different, detail below.

Telephone: Home: Mobile:

Work:

Email:

Alternative contact details? Name:

Provide details of a person the
department can contact if we are Address:
unable to contact you directly. This may
be a friend, relative or an organisation. Telephone: Home:

Work:

Mobile:

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 Application for Social Housing

Note: If more than four household m embers, complete

Applicant details and attach ‘Additional household me mber’ forms before
submitting this application.

Primary applicant’s full name:

Alias:
Any other name you may be known as.

Gender: Date of birth: / / Country of birth:

Do you identify as: Aboriginal Australian South Sea Islander

Tick all that apply.
Torres Strait Islander Other cultural or linguistic background None

Centrelink reference number (CRN):

Department of Veteran Affairs reference number (DVA):

Citizenship/Residency details: Australian citizen Permanent resident

Not permanent resident Visa - what type?

Are you expecting a child? Yes No

If yes, expected due date:

Do you have a medical

condition or disability? Yes No
If yes, provide details:

What is your income? $ Frequency: Type:

Gross amount and type (wages,
pension, allowances, fa mily $ Frequency: Type:
payments, interest, superannuation).

What are your assets? $ Type:

Savings, investments, cash deposits,
property trusts, shares, bonds, $ Type:
debentures, superannuation - allocated
pension or lump sum paym ents, shar e
from property sale or settlement.

Do you own/part own property

in Australia or overseas? Yes No
This includes residential property,
If yes, what type:
vacant land, industrial property,
commercial property, a live-aboard
Address:
boat, cabin, donga, caravan, or
manufactured/ transportable home.
% of property owned:

Current property value:

Ownership date:
What type of transport do
you use? Public Own Other (family and friends)

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 Application for Social Housing

Applicant Household Note: Applicants are people who will sign

the tenancy agreement.
Household member 1 member

What is your relationship with the primary applicant?

Full name:

Alias:
Any other name you may be known as.

Gender: Date of birth: / / Country of birth:

Do you identify as: Aboriginal Australian South Sea Islander

Tick all that apply.
Torres Strait Islander Other cultural or linguistic background None

Centrelink reference number (CRN):

Department of Veteran Affairs reference number (DVA):

Citizenship/Residency details: Australian citizen Permanent resident

Not permanent resident Visa - what type?

Are you expecting a child? Yes No

If yes, expected due date:

Do you have a medical

condition or disability? Yes No
If yes, provide details:

What is your income? $ Frequency: Type:

Gross amount and type (wages,
pension, allowances, fa mily $ Frequency: Type:
payments, interest, superannuation).

What are your assets? $ Type:

Savings, investments, cash deposits,
property trusts, shares, bonds, $ Type:
debentures, superannuation - allocated
pension or lump sum paym ents, shar e
from property sale or settlement.

Do you own/part own property

in Australia or overseas? Yes No
This includes residential property, If yes, what type:
vacant land, industrial property,
commercial property, a live-aboard Address:
boat, cabin, donga, caravan, or
manufactured/ transportable home.
% of property owned:

Current property value:

Ownership date:
What type of transport do
you use? Public Own Other (family and friends)

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 Application for Social Housing

Applicant Household Note: Applicants are people who will sign

Household member 2 member the tenancy agreement.

What is your relationship with the primary applicant?

Full name:

Alias:
Any other name you may be known as.

Gender: Date of birth: / / Country of birth:

Do you identify as: Aboriginal Australian South Sea Islander

Tick all that apply.
Torres Strait Islander Other cultural or linguistic background None

Centrelink reference number (CRN):

Department of Veteran Affairs reference number (DVA):

Citizenship/Residency details: Australian citizen Permanent resident

Not permanent resident Visa - what type?

Are you expecting a child? Yes No

If yes, expected due date:

Do you have a medical

condition or disability? Yes No
If yes, provide details:

What is your income? $ Frequency: Type:

Gross amount and type (wages,
pension, allowances, fa mily $ Frequency: Type:
payments, interest, superannuation).

What are your assets? $ Type:

Savings, investments, cash deposits,
property trusts, shares, bonds, $ Type:
debentures, superannuation - allocated
pension or lump sum paym ents, shar e
from property sale or settlement.

Do you own/part own property

in Australia or overseas? Yes No
This includes residential property, If yes, what type:
vacant land, industrial property,
commercial property, a live-aboard Address:
boat, cabin, donga, caravan, or
manufactured/ transportable home. % of property owned:

Current property value:

Ownership date:
What type of transport do
you use? Public Own Other (family and friends)

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 Application for Social Housing

Applicant Household Note: Applicants are people who will sign

the tenancy agreement.
Household member 3 member
What is your relationship with the primary applicant?

Full name:

Alias:
Any other name you may be known as.

Gender: Date of birth: / / Country of birth:

Do you identify as: Aboriginal Australian South Sea Islander

Tick all that apply.
Torres Strait Islander Other cultural or linguistic background None

Centrelink reference number (CRN):

Department of Veteran Affairs reference number (DVA):

Citizenship/Residency details: Australian citizen Permanent resident

Not permanent resident Visa - what type?

Are you expecting a child? Yes No

If yes, expected due date:

Do you have a medical

condition or disability? Yes No
If yes, please provide details:

What is your income? $ Frequency: Type:

Gross amount and type (wages,
pension, allowances, fa mily $ Frequency: Type:
payments, interest, superannuation).

What are your assets? $ Type:

Savings, investments, cash deposits,
property trusts, shares, bonds, $ Type:
debentures, superannuation - allocated
pension or lump sum paym ents, shar e
from property sale or settlement.

Do you own/part own property

in Australia or overseas? Yes No
This includes residential property,
If yes, what type:
vacant land, industrial property,
commercial property, a live-aboard
Address:
boat, cabin, donga, caravan, or
manufactured/ transportable home.
% of property owned:

Current property value:

Ownership date:
What type of transport do
you use? Public Own Other (family and friends)

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 Application for Social Housing

Your need to move

Does your household need to move for any of the following reasons?
Tick all that apply.
You are experiencing domestic You are a young person in, You need to meet your or a
and family violence exiting or has exited a Youth household member’s disability
Detention Centre support needs

You are experiencing sexual You are in crisis housing You are a long-term patient in a
violence (outside of domestic and provided by a homelessness hospital or health facility and are
family violence) service ready to be discharged

You are experiencing safety You are staying temporarily with You are experiencing a family or
concerns related to violence, family and/or friends and have no relationship breakdown
stalking, abuse (physical, other housing to go to
emotional, financial), or
harassment other than domestic,
family or sexual violence from
another person in your household
or community

The safety of a child in your care You are living on the street, in a You pay more than 30% of your
is at risk car or park, makeshift shelter or gross household income in rent
illegal building
You are in or have just been You are living in a boarding Your housing has been impacted
released from prison house, caravan park or hostel by a natural disaster
that has or is about to be closed

You are a young person (under You are being evicted or about to You are a victim of a major crime
25 years old) currently in, exiting be evicted that was committed in
or has exited State care Queensland

Is your current housing location unsuitable for any of the following reasons?
Tick all that apply.
Too close in proximity to the Too far away from education or Does not enable family
perpetrator of domestic, family, or training services reunification
sexual violence against you

Does not meet the conditions of a Too far away from frequently Does not enable you to gain or
Court Order, Parole or Probation required essential services – maintain regular access or
Order, Family Court Order, transport, medical, disability custody to shared care of
Domestic Violence Order, Child support for daily activities, children
Protection Order transport to meet mobility
requirements

Too far away from family and Distance does not allow you to You are an Aboriginal or Torres
community support which accept a firm offer of employment Strait Islander person and need
impacts on the wellbeing of the – minimum 20 hours per week to move for cultural reasons
household

Is your current housing unsuitable for any of the following reasons?

Tick all that apply.

Design restricts daily living Size is too small resulting in Health and safety issues due to
activities – bathing, mobility, or overcrowding lack of essential facilities or poor
seriously aggravates a medical structural conditions
condition or disability

Note: Co-applicants need to have their individual current housing deemed unsuitable to be eligible for social housing.

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 Application for Social Housing

How much rent does your household currently pay per week?

Is everybody listed on this application currently living with you? Yes No

What type of accommodation is your household currently living in?
For example, private rental, own home, caravan, boarding house, temporary
housing, living with family or friends.

Your financial wellbeing

Do any of the following apply to you or another person in your household?
Tick all that apply.

Unable to work and have high Multiple periods of Currently employed –

levels of living expenses beyond unemployment Part-time
normal living costs related to your
or a household member’s long- Long-term unemployment Full-time
term or serious medical Casual
condition, or permanent and/or
significant disability

Your wellbeing
Have any of the following affected you or your household’s ability to access stable housing?
Tick all that apply.

You or a household member Multiple unsuccessful private You have a history of

have a permanent and significant rental applications homelessness
disability

You or a household member A limited number of or no suitable You afety is at risk from
have a long-term or serious properties to meet needs - size, domestic, family, or sexual
medical condition location or features violence

You safety You have been evicted multiple You are a young person at risk
concerns related to risk of times in the past three years for who requires a tailored
violence, buse, or rent arrears, disruptive response on your path to
harassment behaviour, relationship independence
from breakdown or property damage
another person in your
household or community

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 Application for Social Housing

Your future housing

Where do you want to live? Please list six areas.
You may be offered housing from any of the areas listed below.

Area 1: Area 4:

Area 2: Area 5:

Area 3: Area 6:

What types of housing do you want to apply for?

More than one housing type can be applied for. We will make every effort to offer the type of housing that you have chosen and are eligible for,
however this cannot be guaranteed. Housing with four or more bedrooms is limited.

Townhouses have three or more units next to Cluster housing is several separate homes with two
each other with one to four bedrooms each, divided to four bedrooms each, located within a housing
by common walls. These can be single or double development.
storey and usually have small fenced yards.

Apartments/flats/units are usually a complex of Seniors’ units are only available to applicants over
two or more storeys that may be studio style or 55 years of age and are usually in a complex of one
have up to three bedrooms. These do not have a or two storeys with one to two bedrooms.
separate yard.

Detached houses are one house with two or more Dual Occupancy are two detached houses that are on
bedrooms on its own block of land. one block of land, sometimes with a shared driveway.

Duplexes are usually two units with one to three

bedrooms, each on a block of land, divided by a
common wall. These may be in groups of two to
four.

Do you need modifications to your home to help with daily living activities due to a disability or
medical condition? Yes No
If yes, provide details:
Will you accept housing with
shared facilities? Yes No
Living, bathroom or kitchen facilities may be
shared. If you accept an offer which has
shared facilities, you can choose to remain
listed on the housing register for housing
which has its own facilities.

Do you have any pets? Yes No

If yes, provide details:

Is there any additional information you would like to provide?

Attach another page if necessary.

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 Application for Social Housing

Evidence for your application

All evidence to support your application must be provided
before an assessment can be completed.

Attach evidence about your need to move and your housing needs, for example:
Documentation supporting your reasons for needing to move

For anyone who has a medical condition or disability – completed ‘Medical Report’ form (PH068)

A completed ‘Support Statement’ form (PH076) about your wellbeing

Decision-making – Public Trustee, Guardian, Power of Attorney documentation

Attach evidence about your income and assets

Income – Centrelink income statements, payslips, employer’s declaration/s
Household members over 16 years receiving Centrelink payments can give consent for the department to obtain their income
and assets details electronically from Centrelink.

Assets – quarterly bank statements and documents showing details of all assets and their current valuation

Property ownership – title deed, mortgage documents, contract of sale

Some income, m edical and referral forms are available at www.qld.gov.au/housing or please call or visit your local Housing Service Centre for
forms or advice.

What identification evidence can you and the other applicants provide?
Please tick all that apply.

Primary Secondary

Australian Birth Certificate or extract Bank, credit or ATM card with your signature

Australian Naturalisation or Citizenship Certificate Bank, credit union or building society statements

Australian Permanent Residency Certificate or stamp Centrelink correspondence with CRN

Immicard, Immigration or sponsorship papers Medicare Card

Temporary Protection Visa or stamp Health Care Card

Australian Passport Seniors/Pensioner Card

Australian Driver licence Taxation Assessment Notice

Photograph identification card (Queensland Transport) Australian Marriage Certificate

Adult Proof of Age Card until expiry (Queensland Transport) Australian divorce papers

18+ card until expiry (Queensland Transport) Life Insurance policies

Keypass Card Other photographic identification such as

security identification, cash converters card
Queensland Corrective Services verification

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 Application for Social Housing

Declaration and consent

Personal Information Privacy Notice

The Department of Housing is collecting personal information on this form to provide you with housing
assistance or assess grant funding applications. This is authorised by the Housing Act 2003. To assist you
with your housing needs and services, relevant personal information may, in very limited and specific
circumstances, be disclosed to: partner agencies, service providers, agencies authorised by legislative
provisions, and local governments and non-governmental agencies that now, or will provide you with
housing and/or support services. Limited personal information may be used for housing related research,
policy or planning functions. Unless authorised or required by law, your personal information will not be
passed on to any other third party without your consent. More information about the department’s privacy
policy is available on our website at

I understand:
the instructions given on this form and agree to the above Privacy Notice
the information on this form will be used by the Department of Housing to register my
application for housing assistance, providing I am eligible
my personal information may be given to government and non-government organisations to provide me
with housing and/or support services
that as the applicant/s, I must advise the department if any circumstances change regarding any
household members listed in and that is relevant to this application
that I may become ineligible for housing assistance if changes occur to my or my household’s
circumstances, incomes and/or assets
upon submitting this application, I must provide at least one item from the primary and secondary
identification evidence list above as proof of my identity, one of which, for each applicant, must show a
Queensland address, signature and date of birth.

To the best of my knowledge, the information provided on and in conjunction with this application is true and
correct. I understand that I will commit an offence and be liable to a penalty under the Housing Act 2003 if I
knowingly provide to the Department of Housing false or misleading information that may influence
decisions about my eligibility for housing assistance and may make my application invalid.

Applicant name: Applicant name:

Signed: / / Signed: / /

Date: Date:

I am a Department of Housing employee / registered community housing provider employee / Corrective

Services officer / Justice of the Peace / Commissioner for Declarations / Solicitor.
I have witnessed the above signatures and sighted two of the listed identification evidence items for each
applicant.

Witness name: Position:

Signed: / / Organisation:

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