Regulation 3
1. The name and address of the applicant.
2. The date of birth of the applicant.
3. Whether the applicant is elderly, disabled or infirm.
4. Whether the applicant or his partner is in receipt of income support, an income-based jobseeker’s allowance, working tax credit, or housing benefit.
5. Whether the works are to adapt a property to enable an elderly or infirm person, who lives or proposes to live in the property as his only or main residence, to be cared for.
6. The address of the property to which the application relates.
7. Whether the property is a dwelling or a mobile home.
8. Whether the mobile home qualifies as a dwelling for the purpose of payment of rates and the applicant is in lawful occupation of the mobile home.
9. Whether the applicant lives in the property as his only or main residence.
10. Whether the applicant –
(a)has an owner’s interest in the property;
(b)is a tenant of the property, or
(c)occupies the property under a right of exclusive occupation granted for his life or for a period of more than five years.
11. Where the applicant is a tenant whether the owner is –
(a)the Crown,
(b)a government department (including a department of the Government of the United Kingdom),
(c)the Executive, or
(d)a registered housing association.
12. A description of the works.
13. Whether the works relate to means of escape from fire or other fire precautions.
14. Confirmation that the applicant has a duty or power to carry out the works.
15. The name and address of the person who will carry out the works.
16. An estimate of the cost to the applicant of the works.
17. Confirmation that the works are not, so far as the applicant is aware –
(a)works for which a grant under Chapter II of Part III of the 2003 Order has been approved or for which an application for a grant is pending; or
(b)works which are specified in a group repair scheme approved under Chapter III of that Part or prepared and awaiting approval.
18. Details of the amount or value of any home repair assistance given in respect of the property in the period of three years immediately preceding the date of application.
19. The signature of the applicant or his agent.