Get AU DH1096 2013-2024

Housing Statement Please print in BLOCK LETTERS with a black or blue pen This form is to be completed by an applicant/tenant of social housing to make a statement. This statement MUST be witnessed by an officer of a social housing provider. For information or assistance with this form phone 1300 468 746 24 hours a day seven days a week. Please mark relevant boxes with a If you need more room to answer any questions please include details on a separate page and attach it to this form* Client reference number I the undersigned provide full details T-File number Title Mr Mrs Ms Miss Last name or family name Given name s Unit/House number Street/Avenue Town /Suburb Phone Postcode Mobile Email Do hereby state DH1096 12/13 Page 1 of 2 FACS Privacy Notice This privacy notice applies to the Department of Family and Community Services the Department which consists of the following entities Ageing Disability and Home Care Community Services Housing NSW Strategy and Policy Corporate Services the Land and Housing Corporation the Aboriginal Housing Office and also the Home Care Service. The Department and its related agencies comply with NSW privacy legislation when collecting and managing personal and health information* The information we collect from you or from an authorised third party will be held by the entity that collects it or by NSW Businesslink the Government owned company that provides corporate support to the Department. It will be used to deliver services and to meet our legal responsibilities. We may also use your information within the Department as a whole to plan coordinate and improve the way we provide services. The Department is also legally authorised to disclose information to outside bodies in certain circumstances. Further information about your privacy rights can be found on the Department s website http //www. facs. nsw. gov*au/ siteinformation/privacy or by calling 02 9377 6000 or by emailing privacy facs. nsw. gov*au. Declaration I understand the instructions given on this form* To the best of my knowledge the information provided in this form is correct. or misleading information* Full name please print Signature Date DD / MM / YYYY Full name of witness please print Position Is there another person helping you to fill out this form Yes No If yes that person should read and sign the declaration below I filled in this form on the basis of the information the client gave me. I have read out the form and the answers to the client who seemed to understand them* Contact phone number. Please mark relevant boxes with a If you need more room to answer any questions please include details on a separate page and attach it to this form* Client reference number I the undersigned provide full details T-File number Title Mr Mrs Ms Miss Last name or family name Given name s Unit/House number Street/Avenue Town /Suburb Phone Postcode Mobile Email Do hereby state DH1096 12/13 Page 1 of 2 FACS Privacy Notice This privacy notice applies to the Department of Family and Community Services the Department which consists of the following entities Ageing Disability and Home Care Community Services Housing NSW Strategy and Policy Corporate Services the Land and Housing Corporation the Aboriginal Housing Office and also the Home Care Service. The Department and its related agencies comply with NSW privacy legislation when collecting and managing personal and health information* The information we collect from you or from an authorised third party will be held by the entity that collects it or by NSW Businesslink the Government owned company that provides corporate support to the Department. .