1 Start 2 Complete The Discretionary Adaptations Assistance Grant can help people who own their own home, private tenants, and tenants of social landlords (not council tenants) adapt their homes to meet the needs of disabled children and adults. We are responsible for delivering this grant. If you have any questions, please call us on 01757 705101 or email privatehousingassistance@selby.gov.uk. Housing Grants, Constriction and Regeneration Act 1996 The Housing Renewal Grants (Amendment) (England) regulations 2008 Please note - If you are filling out this application form on behalf of the person requiring the grant assistance, please complete this form with their details. Section 1 - Eligibility checker Are you registered disabled? * Yes No If yes, please provide more information below Are you vulnerable due to age, ill health or low income? * Yes No If yes, please provide more information below Are you vulnerable due to any other special reason? * Yes No If yes, please provide more information below Do you have support from a third party agency? * Yes No Please provide further details of the third party agency supporting your application * Please include name, agency and contact details Are you or your spouse in receipt of any of the following benefits? Income Support Income Related Employment and Support Allowance Income Related Jobseekers Allowance Universal Credit Guaranteed Pension Credit Housing Benefit Working Tax Credit and income less than £15,050 Children’s Tax Credit and income less than £15,050 Please note - if you are not in receipt of any of these benefits, and assessed work is expected to cost more than £6,000 a full means test will be administered. This will take into account both yours and your spouses’ income and savings to determine if you have a contribution to pay towards the work required, either in full or in part. If you are in receipt of a different benefit, please provide the details below Section 2 - Details of the person(s) needing assistance Individual's details: Title * Mr Mrs Miss Ms First name * Second name * Full address (including postcode) * National Insurance Number * Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Telephone/mobile number * Please provide your partner's details below. First name Second name Full Address (including postcode) National Insurance Number Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Telephone/mobile number Section 3 - Details of the property Please provide the details of the type of tenure on the property. Owner Occupier * Yes No Date ownership began Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Privately renting * Yes No Date tenancy began Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Landlord details Renting from an Housing Association * Yes No Landlord details Date tenancy began Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 If other, please provide the details below Please let us about any other people who are living at the property (including their date of birth) * Section 4 - Types of work requiried Please provide details of the work required (include as much details as possible) * Have you made a previous grant application within the last 10 years? * Yes No If yes, please provide the date of when you last made a grant application Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Did you pay a contribution towards the cost of any works? * Yes No If yes, how much did you contribute? Section 5 - Applying on behalf of someone else If you are completing this application for someone else who is requiring this assistance, please provide your details. Name Address Contact details Relationship to person requiring assistance Declaration WARNING: IF YOU KNOWINGLY MAKE A FALSE STATEMENT, YOU MAY BE LIABLE TO PROSECUTION I/We declare that to the best of my knowledge information and belief, the information I/We have given above is correct. I am: [the applicant] [one of the applicants] [the relevant person (but not the applicant or one of the applicants)] [a relevant person (but not the applicant or one of the applicants)]. Name * I have completed the application to the best of my knowledge information and belief, the information I/We have given above is correct * I agree Today's date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20212022202320242025
