Forms home Disabled Adaptations Grant Step 1 of 123 0% You cannot proceed with this application! If you have not yet been assessed by an Occupational Therapist, please complete this online form to request assessment for adults, or visit this website to request an assessment for a child.Confirmation I confirm that I have been assessed by an Occupational Therapist (OT). Occupational Therapist detailsName of the Occupational Therapist visited Date of Visit Day Month Year You may receive a maximum of £30,000 dependent on what we decide is a reasonable cost for the work you need. If the works amount to more than £19,000 a charge will be placed on your property. This means if you sell your house within 5 years of completing the work you have to repay the full amount or £10,000 whichever is the lesser amount. If you require assistance completing the form, please contact the Home Improvement Team. Confirmation(Required) I understand that no work should be carried out until I have written confirmation of grant approval. What will we do with information you provide? The Home Improvement Team of the London Borough of Redbridge will be collecting this information to process your application for a grant. Some of the data we collect will be personal data about you. This will include amongst other things: name, residential address and date of birth. We will also collect details of household income, benefits and all those living at your address. We review our retention periods of the information we hold about you on a regular basis. We are legally required to hold some types of information to fulfil our statutory obligations. We will hold your personal information on our systems for as long as it is necessary for the service that we provide to you, or as required by law. The information you provide may be shared with other enforcement agencies and local authorities nationally where breaches of statutory legislation are suspected. We may also be obligated to share your personal details with other organisations for crime and taxation purposes including for the prevention or detection of crime, the capture or prosecution of offenders; and the assessment or collection of tax or duty under section 29 of the Data Protection Act. We will not use your information for marketing. Further information on how we process your data and your rights can be found in our privacy policy online at www.redbridge.gov.uk Who is the adaption for?Is the adaption work for a disabled child?(Required) Yes No Child's Firstname(Required) Child's Surname(Required) Child's Date of Birth(Required) Day Month Year Your details Your (Disabled person's) detailsTitle(Required)MrMrsMissMsOtherIf other, please specify(Required) Firstname(Required) Surname(Required) Your details Your (Disabled person's) detailsDate of Birth(Required) Day Month Year National Insurance Number(Required) Your details Your (Disabled person's) detailsYour Email address(Required) Telephone number(s)(Required) Your detailsYour (Disabled person's) detailsAre you a student?(Required) Yes No Marital Status(Required) Single Married/Partner/living together Marital status refers to the relationship you have with the partner you live with. For the purpose of this form, partner includes both same sex partners and partners of the opposite sex, whether married or living together. Your property details What is the property address where the grant works will be carried out?(Required)Find addressSelected address Do you own the above property?(Required) Yes No Please enter the details of the owner (Private landlord’s name or Housing association name)(Required) Does anyone else shares ownership of this property?(Required) Yes No Please give details of the person who shares the ownership of the propertyTitle(Required)MrMrsMissMsOtherIf other, please specify(Required) Firstname(Required) Surname(Required) Spouse/Partner detailsSpouse/Partner details of a disabled personTitle(Required)MrMrsMissMsOtherIf other, please specify(Required) Firstname(Required) Surname(Required) Spouse/Partner detailsSpouse/Partner details of a disabled personDate of Birth(Required) Day Month Year National Insurance Number(Required) Spouse/Partner detailsSpouse/Partner details of a disabled personEmail address(Required) Telephone number(s)(Required) Other household membersPlease list all the people who live in your home (other than you and your Spouse/Partner)NameRelationship to you (e.g. son, daughter)Date of birthWhat they do (e.g. work, school, student)Please state if disabled or have long term serious illness Add Remove Contact someone else on your behalfDo you want us to contact someone else on your behalf(Required) Yes No Please give details of the person to contactTitle(Required)MrMrsMissMsOtherIf other, please specify(Required) Firstname(Required) Surname(Required) Telephone number(s)(Required) Your BenefitsDo you or your Spouse/Partner receive any of these benefits(Required) Employment Support Allowance (Income Related) Income Support Housing Benefit Council Tax Benefit Working Tax Credit Child Tax Credit Guaranteed Pension Credit Universal Credit None of the above Please attach the selected benefit letter(s). Drop files here or Select files Max. file size: 10 MB. If you do not have it right now, please email it to Home Improvement Team By providing the financial information in the next part, we will be able to assess whether you are eligible for additional funding to help with the cost of the adaptation. If you choose not to provide this information, the maximum grant available will be limited to £19,000 and you will have to pay any costs exceeding that amount. If during your application, we identify the need for additional funding, we will give you the opportunity to answer these questions again in a paper form. Financial information Yes, I agree to provide my financial information. No, I will provide this later if required. Children under the age of 19Do you have any children under the age of 19?(Required) Yes No Please give details of children under the age of 19(Required)NameRelationship to youDate of birthAre they blind or getting Disability Living Allowance (DLA)Do they get High rate DLA Add Remove Yours other Property Do you own any other properties other than the one you live in?(Required) Yes No Please provide address of this property(Required)Find addressSelected address Yours other Property detailsDo you receive rent for this property?(Required) Yes No What is the monthly rent you receive? Yours other Property detailsWhat type of property is this?(Required) Semi detached house Flat Other How many bedrooms does the property have? Yours other Property detailsIs there any outstanding mortgage on the property?(Required) Yes No What is the outstanding balance? Do you have any other loans secured against this property?(Required) Yes No How much is the secured loan? Yours other Property detailsWhose names are on the deeds? Whose names are on the Mortgage? Spouse/Partner's other property Does your spouse/partner own any other properties other than the one you live in?(Required) Yes No Please provide address of this property(Required)Find addressSelected address Spouse/Partner's other property detailsDoes your spouse/partner receive rent?(Required) Yes No What is the monthly rent your spouse receives? Spouse/Partner's other property detailsWhat type of property your spouse/partner has?(Required) Semi detached house Flat Other How many bedrooms does the property have? Spouse/Partner's other property detailsIs there any outstanding mortgage on the property your spouse/partner owns?(Required) Yes No What is the outstanding balance? Does your spouse/partner have any other loans secured against this property?(Required) Yes No How much is the secured loan? Spouse/Partner's other property detailsWhose names are on the deeds? Whose names are on the mortgage? Are you registered as blind?(Required) Yes No Do you have a mobility car?(Required) Yes No Is your Spouse/Partner registered as blind?(Required) Yes No Does your Spouse/Partner have a mobility car?(Required) Yes No Your BenefitsPlease select the benefits you receive Attendance allowance Disability living allowance – care component Disability living allowance – mobility component Severe disablement allowance Incapacity benefit Statutory sick pay Statutory maternity pay Statutory paternity pay Statutory adoption pay Maternity allowance Carer’s allowance Carer’s allowance – Does anyone receive carers allowance for caring for you? Job seeker’s allowance Income based Job seeker’s allowance Bereavement benefit Child benefit Industrial injuries disablement benefit Any other benefits – please state amount and how often paid Your Attendance allowanceRate(Required) Lower rate Higher rate Amount(Required) How often(Required) Your Disability living allowance – Care componentRate(Required) Lower rate Middle rate Higher rate Amount(Required) How often(Required) Your Disability living allowance – Mobility componentRate(Required) Lower rate Middle rate Higher rate Amount(Required) How often(Required) Your Severe disablement allowanceAmount(Required) How often(Required) Your Incapacity benefitRate(Required) Lower rate Higher rate Amount(Required) How often(Required) Your Statutory sick payAmount(Required) How often(Required) Your Statutory Maternity payAmount(Required) How often(Required) Your Statutory Paternity payAmount(Required) How often(Required) Your Statutory Adoption payAmount(Required) How often(Required) Your Maternity allowanceAmount(Required) How often(Required) Your Carer’s allowanceAmount(Required) How often(Required) Your Carer’s allowance – Does anyone receive carers allowance for caring for youAmount(Required) How often(Required) Your Job seeker’s allowanceAmount(Required) How often(Required) Your Income based Job seeker’s allowanceAmount(Required) How often(Required) Your Bereavement benefitAmount(Required) How often(Required) Your Child benefitAmount(Required) How often(Required) Your Industrial injuries disablement benefitAmount(Required) How often(Required) Your other benefitsIf any other benefits – please specify(Required)Benefit receivedAmountHow often Add Remove Spouse/Partner's Benefits Please select the benefits your Spouce/Partner receive Attendance allowance Disability living allowance – care component Disability living allowance – mobility component Severe disablement allowance Incapacity benefit Statutory sick pay Statutory maternity pay Statutory paternity pay Statutory adoption pay Maternity allowance Carer’s allowance Carer’s allowance – Does anyone receive carers allowance for caring for you? Job seeker’s allowance Income based Job seeker’s allowance Bereavement benefit Child benefit Industrial injuries disablement benefit Any other benefits – please state amount and how often paid Spouse/Partner's Attendance allowanceRate(Required) Lower rate Higher rate Amount(Required) How often(Required) Spouse/Partner's Disability living allowance – Care componentRate(Required) Lower rate Middle rate Higher rate Amount(Required) How often(Required) Spouse/Partner's Disability living allowance – Mobility componentRate(Required) Lower rate Higher rate Amount(Required) How often(Required) Spouse/Partner's Severe disablement allowanceAmount(Required) How often(Required) Spouse/Partner's Incapacity benefitTerm(Required) Short term Long term Amount(Required) How often(Required) Spouse/Partner's Statutory sick payAmount(Required) How often(Required) Spouse/Partner's Statutory Maternity payAmount(Required) How often(Required) Spouse/Partner's Statutory Paternity payHow often(Required) Amount(Required) Spouse/Partner's Statutory adoption payAmount(Required) How often(Required) Spouse/Partner's Maternity allowanceAmount(Required) How often(Required) Spouse/Partner's Carer’s allowanceAmount(Required) How often(Required) Spouse/Partner's Carer’s allowance – Does anyone receive carers allowance for caring for your Spouce/PartnerAmount(Required) How often(Required) Spouse/Partner's Job seeker’s allowanceAmount(Required) How often(Required) Spouse/Partner's Income based Job seeker’s allowanceAmount(Required) How often(Required) Spouse/Partner's Bereavement benefitAmount(Required) How often(Required) Spouse/Partner's Child benefitAmount(Required) How often(Required) Spouse/Partner's Industrial injuries disablement benefitAmount(Required) How often(Required) Spouse/Partner's any other benefitsIf any other benefits – please specify(Required)Benefit receivedAmountHow often Add Remove Your EarningsAre you currently employed?(Required) Yes No Please provide the following information about your earningsHow many hours per week do you work?(Required) Employer Name(Required) Employer Address(Required) Occupation(Required) Please provide the following information about your earningsGross income from employment (before deductions)(Required) National insurance paid Taxes paid Pension contributions Your Spouse/Partner EarningsIs your spouse/partner currently employed?(Required) Yes No Please provide your Spouse/Partner's information about earningsHow many hours per week does your spouse/partner work?(Required) Employer name of your Spouse/Partner(Required) Employment address of your Spouse/Partner(Required) Occupation of your Spouse/Partner(Required) Please provide your Spouse/Partner's information about earningsGross income (before deductions) of your Spouse/Partner(Required) National insurance paid by your Spouse/Partner Taxes paid by your Spouse/Partner Pension contribution by your Spouse/Partner If you or your partner are self-employed please supply a “Statement of Net Profit” for the past 3 years. Your Other Income Do you receive any of the other income? Income from tenants, sub-tenants or persons to whom you provide board and lodging Maintenance from a former partner Income from shares held Your Income from tenants, sub-tenants or persons to whom you provide board and lodgingAmount(Required) How often(Required) Weekly Monthly Yearly Your Income for Maintenance from a former partnerAmount(Required) How often(Required) Weekly Monthly Yearly Your Income from shares heldAmount(Required) How often(Required) Weekly Monthly Yearly Spouse/Partner's Other IncomeDoes your spouse/partner receive any of these other income? Income from tenants, sub-tenants or persons to whom you provide board and lodging Maintenance from a former partner Income from shares held Spouse/Partner's Income from tenants, sub-tenants or persons to whom you provide board and lodgingAmount(Required) How often(Required) Weekly Monthly Yearly Spouse/Partner's Income for Maintenance from a former partnerAmount(Required) How often(Required) Weekly Monthly Yearly Spouse/Partner's Income from shares heldAmount(Required) How often(Required) Weekly Monthly Yearly Your PensionsDo you receive any of these pensions? State Retirement Pension Occupational pension (i.e. pension received from previous employer) Personal pension Retirement annuity Any other pensions Your State Retirement PensionAmount(Required) How often(Required) 4 Weekly Monthly Yearly Your Occupational pension (i.e. pension received from previous employer)Amount(Required) How often(Required) Weekly Monthly Yearly Your Personal pensionAmount(Required) How often(Required) Weekly Monthly Yearly Your Retirement annuityAmount(Required) How often(Required) Weekly Monthly Yearly Your any other pension(s)Please give details of type of pension you receive(Required) Amount(Required) How often(Required) Weekly Monthly Yearly Spouse/Partner's PensionDoes your Spouse/Partner receive any of these pensions? State Retirement Pension Occupational pension (i.e. pension received from previous employer) Personal pension Retirement annuity Any other pensions Spouse/Partner's State Retirement PensionAmount(Required) How often(Required) 4 Weekly Monthly Yearly Spouse/Partner's Occupational pension (i.e. pension received from previous employer)Amount(Required) How often(Required) Weekly Monthly Yearly Spouse/Partner's Personal pensionAmount(Required) How often(Required) Weekly Monthly Yearly Spouse/Partner's Retirement annuityAmount(Required) How often(Required) Weekly Monthly Yearly Spouse/Partner's Other pensionsPlease give details of type of pension you receive(Required) Amount(Required) How often(Required) Weekly Monthly Yearly Your Savings & Investments Please give details of all savings or other investments both individually and jointly owned by you and your partner, stating current balance where applicable. Please provide up to date bank/savings statements.Please select the savings and investments you have Bank current account (s) Building Society account(s) Post Office account(s) Premium bonds (number held) ISA’s Other investents Your savings in BankBank current account (s)(Required) Amount(Required) Your savings in building societyBuilding Society account(s)(Required) Amount(Required) Your savings in Post officePost Office account(s)(Required) Amount(Required) Your savings in Premium bondsPremium bonds (number held)(Required) Amount(Required) Your savings in ISA'sISA’s(Required) Amount(Required) Your other InvestmentsPlease give details of the investment(Required) Amount(Required) Your Spouse/Partner's Savings & InvestmentsPlease give details of all your Spouse/Partner savings or other investments both individually and jointly owned by you and your partner, stating current balance where applicable. Please provide up to date bank/savings statements.Please select the savings and investments your spouce/Partner have Bank current account (s) Building Society account(s) Post Office account(s) Premium bonds (number held) ISA’s Other investents Spouse/Partner's savings in BankBank current account (s)(Required) Amount(Required) Spouse/Partner's savings in Building SocietyBuilding Society account(s)(Required) Amount(Required) Spouse/Partner's savings in Post OfficePost Office account(s)(Required) Amount(Required) Spouse/Partner's savings in Premium bondsPremium bonds (number held)(Required) Amount(Required) Spouse/Partner's savings in ISA AccountsISA Account(s)(Required) Amount(Required) Spouse/Partner's other InvestmentsPlease give details of investment(Required) Amount(Required) Your Financial Information Are you unable to work because of sickness for at least the last 28 weeks?(Required) Yes No If yes, please give details: Are you unable to work because of sickness for at least 364 days?(Required) Yes No If yes, please give details: Are you provided with a vehicle, or receiving an allowance in respect of such a vehicle? (including via the mobility scheme)(Required) Yes No If yes, please give details: Spouse/Partner's Financial InformationIs your Spouse/Partner unable to work because of sickness for at least the last 28 weeks?(Required) Yes No If yes, please give details: Is your Spouce/Partner unable to work because of sickness for at least 364 days?(Required) Yes No If yes, please give details: Is your partner provided with a vehicle, or receiving an allowance in respect of such a vehicle? (including via the mobility scheme)(Required) Yes No Your Eligible outings Allowance may be made for certain specific household outgoings. In order to complete your application, please provide the following informationIf you make, or are treated as making, a contribution in respect of a student grant or student loan for a child or partner, please give details. Your Eligible outingsDo you pay for childcare?(Required) Yes No Child’s full name(Required) Date of birth Day Month Year Name of the person/organization providing care:(Required) Childcare that you payAddress of the person/organization providing care(Required) Address Line 1 Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County (optional) Postcode How many days / hours is care provided?(Required) Cost per week:(Required) How often paid:(Required) Spouse/Partner eligible outings Allowance may be made for certain specific household outgoings. In order to complete your application, please provide the following informationIf your spouse/partner makes, or is treated as making, a contribution in respect of a student grant or student loan for a child or partner, please give details Childcare that your Spouse/Partner paysDoes your spouse/partner pay childcare?(Required) Yes No Child’s full name(Required) Date of birth Day Month Year Name of the person/organization providing care:(Required) Address of the person/organization providing care(Required) Address Line 1 Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County (optional) Postcode Childcare that your Spouse/Partner paysHow many days / hours is care provided?(Required) Cost per week:(Required) How often paid:(Required) ContractorPlease select your preferred method(Required) I would like the Council to arrange to carry out the works on my behalf by sourcing a contractor. The Council operates a Dynamic Purchasing System (DPS) to support DFG applicants and those in need of minor building works to meet their home environmental needs in engaging with reputable and compliant contractors. Independence Community Interest Company manage the DPS on behalf of the London Borough of Redbridge. I would like to source my own contractor to undertake the adaptation work. I understand that I will be required to submit 2 or 3 quotations for the adaptation(s) from an approved contractor to ensure that the grant awarded is fair value. I understand that I must provide an itemised quotation to demonstrate that I have met the Occupational Therapists specification. I will also need to provide a valid invoice in order for the Council to pay the grant. It is important to note that as the work is being carried out on your home the contract for works will be between you and the contractor. This means the council is not responsible should you have and dispute with a contractor during or after the works are complete. Diversity MonitoringGender Male Female Is your gender identity the same as at birth Yes No Age 0-17 18-24 25-34 35-44 45-54 55-64 65+ Diversity MonitoringDo you consider yourself to have a disability?(Required) Yes No Please select the diability you have(Required) Hearing Reduced Mobility Mental health Illness Speech Other disability If other disability, please specify(Required) Diversity MonitoringSexual orientation Heterosexual Lesbian Gay Bi –sexual Prefer not to say Religion/Beliefs Christian Jewish Muslim Sikh Buddhist Hindu None Any other religion Diversity MonitoringEthnicity White British White Irish White Scottish White Welsh Gypsy Irish Traveller Any other White background White and Caribbean White and African White and Asian Any other mixed background Indian Pakistani Bangladeshi Any other Asian background Black/Black British Black Caribbean Black African Any other black background Chinese Any other ethnic group If other Ethinic group, please specify(Required) DeclarationDeclaration(Required) By selecting, I declare that to the best of my knowledge, the information I have provided is correct. WARNING: If you knowingly make a false statement, you may be liable to prosecution. I understand the following(Required) WARNING: If you knowingly make a false statement, you may be liable to prosecution. If you knowingly make a false statement, you may be liable to prosecution. By signing this form, I declare that to the best of my knowledge, the information I have provided above is correct. I INTEND that, throughout the grant condition period of 5 years, or such shorter period as health permits, the property will be my only or main residence. I UNDERSTAND that, if a grant is approved, any breach of the grant conditions may require the full amount of the grant to be repaid to the Council. I UNDERSTAND that it is my responsibility to inform my mortgage provider/freeholder (where applicable) about my grant application and its conditions. Please note: - You must supply proof of benefit and any income.
