Download Report

APPLICATION FOR A UNIT
Thank you for your enquiry regarding a unit at Sirovilla. Sirovilla provides long term
affordable housing for older persons under the Retirement Villages Act 1986. Sirovilla
allocates vacant units by a wait in turn list. There is considerable demand for this type
of accommodation and it may take several years for applicants to be offered a unit.
Applicants should consider their future housing and support needs with this timeframe
in mind prior to submitting an application.
This form will assist Sirovilla to determine your eligibility for a unit. The eligibility criteria are:
•
•
•
aged over 65 for men and 60 for women
capable of living independently – there are no on site support services
able to demonstrate a connection to the Geelong region/community
After completing the application form it is important that potential applicants arrange
an interview in person or by phone with the Resident Services Coordinator. The
interview will need to be completed prior to an applicant going onto the waiting list.
Please contact the office on 03 5241 1517 to arrange an appointment.
Please note it is the responsibility of applicants to advise Sirovilla if their circumstances
change, especially a change of address. Sirovilla will make regular contact by post with
applicants to confirm their ongoing interest in living at Sirovilla while on the waiting
list. If applicants do not respond to the written letter requesting their confirmation of
their ongoing interest they may be removed from the waiting list.
Completed application forms are to be sent to:
Resident Services Coordinator
Sirovilla Retirement Village
32-52 Broughton Drive
Highton 3216
APPLICATION
Please select


Sirovilla
32-52 Broughton Drive,
Highton VIC 3216
Lions Village Anglesea
32-34 Murray Street, Anglesea VIC 3230
CONTACT DETAILS
Name_____________________________________________________________________________________
Address __________________________________________________________________________________
___________________________________________________________________ Post Code........................
Phone No___________________________________ Mob ________________________________________
APPLICANT(S) DETAILS
Name_____________________________________________________________________________________
Address __________________________________________________________________________________
Post Code
Date of Birth _____________________________________________________________________________
Pension No (CRN _________________________________________________________________________
Phone No___________________________________ Mobile ______________________________________
Email address ____________________________________________________________________________
Partner’s Name ___________________________________________________________________________
Partner’s Date of Birth______________________
Partner’s Pension No (CRN _______________________________________________________________
NEXT OF KIN
Name and address of next of kin (or other suitable contact in case we can’t contact
you):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Relationship to the applicant _____________________________________________________________
Phone No___________________________________
CURRENT CIRCUMSTANCES
Please describe your current housing situation
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Do you own a vehicle?
Yes
□
No
□
If Yes - Make & Model ________________________________________________________________
Do you have any pets?
Yes
□
No
□
If Yes - Type & Age _______________________________________________________________________
FINANCIAL INFORMATION
Please tick one or more of the following boxes in order to allow Sirovilla to determine
your household income. You may be requested to provide a current income statement
on your household’s income. Please give fortnightly amount
Centrelink Aged Pension
□ $p/f
Veterans Affairs Pension
□ $ .................................p/f
Disability Support Pension
□ $..................................p/f
Overseas Pension
□ $ .................................p/f
Other Income
□ $ ..................................p/f
Please specify ____________________________________________________________________________
ASSETS
Do you own (or part own) a residential property?
□
No
□
Do you have assets that give you an income?
□
No
Yes
Yes
□
If yes, please state your gross household fortnightly income ____________________________
Does your household have a total of less than $30,000 in realisable assets?
(This includes savings, investments, shares and recreational vehicles ie boats or
caravans)
□
Yes .................
No............
□
HOUSING NEEDS
Do you or your partner have any health issues which affect your housing needs (eg a
disability, ramp, wheelchairs, accessibility)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
YOUR CONNECTION WITH THE GEELONG AND/OR ANGLESEA AREA
Do you have links with the Geelong and/or Anglesea region?
Yes .......
□
□
No........
This can include links such as family, friends, or you may have lived in the area in the
past. Please use the space below to tell us about your links to the Geelong region:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
OTHER INFORMATION
Please use the space below to tell us anything about your housing needs which may
help us assess your application for housing.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
APPLICANT DECLARATION
To the best of my knowledge, the information I have given on this form is true and
correct.
Signed ______________________________________
Date____ _________________________________
Print Name _______________________________________________________________________________
Privacy Statement I consent to the information contained within this application being collected, used
and disclosed by Sirovilla solely for purposes outlined in the Sirovilla Privacy Policy and that I can access
the Sirovilla Privacy Policy at the Sirovilla Office. I understand that I can request to view any information
supplied by me and held by Sirovilla.
Retirement Villages managed:
Sirovilla 32-52 Broughton Drive Highton VIC 3216 • Ph: 03 5241 1517
Lions Village Anglesea 32-34 Murray Street Anglesea VIC 3230 • Ph: 03 5241 1517 Sirovilla.org.au