Tenancy Hardship Grant (THG) Application Form

Address *

Phone *

Email *

Landlord or agent’s details:

Name *

Address *

Phone *

Please tell us why you are applying for a THG? (please tick all that apply – this is to provide the local authority with information on your immediate need for housing assistance)

I have more than 8 weeks of rent arrears between 1st March 2020 – 30th June 2021 which were caused by Covid-19 and I can explain and evidence this.

I live in a private rented property and have been unable to address my rent arrears caused by Covid-19.

I was not in receipt of housing related benefits when my rent arrears built up.

I am not currently in receipt of housing related benefits.

I have been served a notice of eviction by my landlord or agent and am at risk of homelessness.

I have spoken to my landlord or agent about my rent arrears, and I have been unable to agree an affordable repayment plan.

Rental information

Please tell us the amount of rent you pay per week or month

Amount *

I pay *

Weekly
Monthly

Breakdown of Rental Arrears by monthly rental period from 1st March 2020 to 30th June 2021:

From*	To*	Monthly Rent*

Total value of rent arrears *

The reason I have got into rent arrears because of Covid-19 is: *

I confirm that the information provided on the value of my rent payment and arrears is correct and understand that this will be verified with my landlord or agent *

1. About you and your Household

Information about you

Name *

Date of Birth: *

NI number: *

Employment Status: *

Employer's name *

Type of contract: *

Average monthly net income before Covid-19 was (£): *

Average monthly net income during Covid-19 was (£): *

Average hours worked per month before Covid-19 was: *

Average hours worked per month during Covid-19 was: *

Number of dependants: *

Ages:

Information about my partner

Do you live with a partner? *

Name *

Date of Birth: *

NI number: *

Employment Status: *

Employer's name *

Type of contract: *

Average monthly net income before Covid-19 was (£): *

Average monthly net income during Covid-19 was (£): *

Average hours worked per month before Covid-19 was: *

Average hours worked per month during Covid-19 was: *

Number of dependants: *

Ages: *

About other people in the household – non dependants

First person

Do you live with any people who are non-dependants? *

Name *

Ages: *

Average monthly net income during Covid-19 was (£): *

ESA/JSA/Universal Credit/Pension credit claimant? *

Contribution towards household costs? (value £) *

Second person

Do you live with any people who are non-dependants? *

Name *

Ages: *

Average monthly net income during Covid-19 was (£): *

ESA/JSA/Universal Credit/Pension credit claimant? *

Contribution towards household costs? (value £) *

Financial Details

For the period that your rent arrears built up, during Covid-19, please fill in the necessary financial information requested.

Income:

Net income is the amount after deductions such as income tax.
Include any benefit you receive as income.
Include the contribution towards household costs from non-dependants shown above (if applicable).

Pay period *	Net income	Amount (£) *	Type of income *	Description

Outgoings:

In the “Due” column enter a character representing Monthly/ Weekly/ Fortnightly/ Quarterly/ 6-Monthly/Yearly/Irregular.

Due *	Amount (£) *	Type of Payment *	Description

Savings:

If you have savings, but they are earmarked for an important item, please indicate below and provide a reason.

Type *	Amount (£) *	Institution	Reference	Plans

Declaration

Please read this declaration carefully before you sign and date it.
1. I declare that I have read and understood the eligibility and evidence requirement for applying for a THG and the information given on this form is true and accurate.
2. I agree that the local authority may make enquiries necessary to check the information I have given.
3. If it is discovered that payments have been made in error or have been claimed as a result of fraud, recovery action will be taken and prosecution will be initiated.
4. I agree to provide the evidence to support my application including my income/expenditure when requested, and further information relating to my application where asked.
5. I understand that the local authority will need to review my application and verify the details with my landlord or agent, before it can be considered.
6. I understand that the local authority will check that my landlord is registered with Rent Smart Wales, and will report any unregistered properties.
7. I have not already received a Tenancy Saver Loan (TSL) or a grant towards the rent arrears that I am applying for help with through this application.
8. I understand that my application might be unsuccessful, and that I will be provided with the reason why.