Application Form - Home & Central East Aged Care Alliance Inc (CEACA)

Surname

First Names

Title

Gender

Address - (optional)

ZIP / Postal Code

Telephone

Mobile

Email Address

Date of birth

Marital Status

Next of Kin

Telephone

Address

ZIP / Postal Code

Do you have any pets?Note: Roosters/Chickens/Livestock not permitted.

If YES, please state number of pets, age(s) and breed(s)

Are you, your partner and/ or co-applicant/s own / part owner or are you in the process of buying residential land or property?

If you answered YES, what is the approximate value of the land or property?

Are you currently renting this property out to a third party?

If the answer is yes, what is the weekly rent?

Please give the reason for you not occupying these premises:

Type of Income and provide a copy of your current “Centrelink Income Statement”:

CRN / Policy No

Please Specify

Have you or your partner previously rented accommodation(If Yes, Please complete rental referee details below).

Previous Landlord’s Name: *

Phone No *0 / 10

Character Reference

A character reference must be provided in writing for both the Applicant and the Co-Applicant. The referee must have known the applicant(s) for 5+ years. The reference can be emailed to info@ceaca.org.au or sent to 0414 136 687. Please ensure that the name of the applicants is included in the reference.

Disability / Medical Information:

CEACA units are designed for independent living and as such, may assist tenants to source relevant local service providers to meet their ongoing needs, but will not recommend them. CEACA takes no responsibility for the provision of care or services by other agencies or providers.

It is the responsibility of the tenant to conduct the relevant checks prior to entering into any agreements with them. It is in your best interest to advise CEACA if anyone in your household has a disability or medical condition so that CEACA can provide you with the relevant contact details for services and organisations in the Wheatbelt area.

Do you have a registered disability and can provide proof of such?

Nature of Disability

MAIN APPLICANT - INCOME AND ASSETS

This section must be completed. If you are unsure of what constitutes assets or other income, please feel free to contact us info@ceaca.org.au

Your Gross Weekly Income

Govt Benefit type

Payment amount

Wages /Salary

Bank Savings (Total of all account

Cash Assets (Definitions on Page 4 & 5 of Application Form) eg. Personal effects/vehicles

Other Income

Residency status

CO-APPLICANT

Please give details of anyone who will be residing in the unit with you.

Surname

First Names

Date of birth

Address

ZIP / Postal Code

Email Address

Mobile No *0 / 10

Title

Gender

CO-APPLICANT - INCOME AND ASSETS

This section must be completed. If you are unsure of what constitutes assets or other income, please feel free to contact us info@ceaca.org.au

Your Gross Weekly Income

Govt Benefit type

Payment amount

Wages /Salary

Bank Savings (Total of all account

Cash Assets (Definitions on Page 4 & 5 of Application Form) eg. Personal effects/vehicles

Other Income

Residency status

Is there any other information regarding your personal circumstances that may be relevant to your application?

Signed (Applicant)

Date

Signed (Co-Applicant)

Date

Warning: It is important the details of your application are true and accurate. A false or misleading declaration will result in the withdrawal of your application and the loss of your place on the waiting list. If a unit is offered and the information given has been found to be misleading, CEACA reserve the right to issue a termination of lease.

Note: Applicants who own or part-own property but are unable to reside in the property may be deemed eligible subject to consideration of their circumstances. Examples include: the property is uninhabitable; domestic violence; family separation; inherited property that has multiple owners or is interstate, seniors unable to live in their property because of mobility requirements; and/or properties that cannot be sold due to market or legal constraints.

Information To Be Attached To Application (All Applicants)

Bank Statement(s) – Page showing balance only of all accountsDrivers Licence/Passport (Photo ID)Centrelink StatementPayslips x 2 (if applicable)Character ReferenceLandlord ReferenceLetter from GP confirming you able to live independently if applying for a Platinum/Disability Unit

Attach Documents

Document Code: CEACA-FRM-002
Date Effective: 22/03/2022
Version Number: 3.0

Preferred Area

Information To Be Attached To Application (All Applicants)

Document Code: CEACA-FRM-002 Date Effective: 22/03/2022 Version Number: 3.0

Preferred Area

Information To Be Attached To Application (All Applicants)

Document Code: CEACA-FRM-002
Date Effective: 22/03/2022
Version Number: 3.0