PGS Homeowner Application – SUPPORTMATCH HOMESHARE

HOMEOWNER/HOUSEHOLDER PERSONAL INFORMATION

Welcome to Supportmatch Homeshare.

Please use this Application Form if you are the Homeowner and would like to register for our Property Guardianship Scheme, wherein you will receive a fixed amount each month that you request for a room you are happy to offer to a NHS Key worker, social worker, professional or mature student.

The Majority our Guardians and Homesharers are working professional, Mature Students, Key Workers (Doctors, Nurses, Carers) who are in need of Affordable Accommodation.

Terms & Conditions: By completing and submitting this Property Guardianship Service (PGS) application you are agreeing to our Terms and Conditions.Terms & Conditions: By completing and submitting this Property Guardianship Service (PGS) application you are agreeing to our Terms and Conditions.

FULL NAME (Required)

First

Last

HOMEOWNER/ HOUSEHOLDERS FULL NAME

GENDER (Required)

FEMALE
MALE
OTHER

DATE OF BIRTH (Required)

PHONE (Required)

EMAIL ADDRESS (Required)

ADDRESS (Required)

Address Line 1

City

State / Province / Region

Postal Code

Country

ARE YOU THE PROPERTY OWNER (Required)

YES
NO

IF YOU ARE NOT THE PROPERTY OWNER, DO YOU HAVE PERMISSION FROM THE OWNER/LANDLORD TO OFFER A ROOM TO GUARDIAN (Required)

YES
NO
OTHER

To meet the requirements for Guardianship under Supportmatch please ensure you have the permission of the Homeowner, Property Owner of Landlord to permit a person to live in a spare room in your home. If you are the Power of Attorney completing this application on behalf of the Householder then we would like you to confirm that you have permission to act on behalf of the Householder, Homeowner or Tenant in this case.

IF OTHER BRIEFLY PLEASE EXPLAIN THE ARRANGEMENT (Required)

IS THE PROPERTY UNDER A HMO OR SELECTIVE PROPERTY LICENCE (Required)

YES
NO
NOT APPLICABLE

Note: HMO is a House of Multiple Occupancy

DO YOU HAVE A CURRENT GAS SAFETY CERTIFICATE FOR THE PROPERTY (Required)

YES
NO
I DON'T KNOW

This is important for your safety and that of any Guardian guest that you licence a room to.

DO YOU HAVE WORKING SMOKE & CARBON MONOXIDE ALARMS IN THE PROPERY (Required)

YES
NO
I DON'T KNOW

This is important for your safety and that of any Guardian guest that you licence a room to.

ARE YOUR ELECTRICAL HOME APPLIANCES AND PLUG SOCKETS SAFE AND COMPLIANT (Required)

YES
NO
I DON'T KNOW

This is important for your safety and that of any Guardian guest that you licence a room to.

EMERGENCY CONTACT OR NEXT OF KIN (NOK)

We Recommend That All Our Homeshare Householder provide us with an Emergency Contact.

NOK Full Name (Required)

NOK Full Address (Required)

Address Line 1

City

State / Province / Region

Postal Code

Country

NOK Phone (Required)

NOK Email Address (Required)

NOK Relationship to Householder (Required)

RELATIVE
FRIEND
OTHER

CONTACT & POWER OF ATTORNEY INFORMATION

Where Applicable Please Provide Information about any person who has Power of Attorney Responsibility in relation to the Homeshare Householder Applicant.

POA: Does a Power-of-Attorney Authority Exist for the Householder (Applicant)? (Required)

YES
NO

PoA Full Name (Required)

Please provide the Full Name of the PoA

PoA Email Address (Required)

PoA Phone

ACCOMMODATION/SPAREROOM OFFERED BY HOMEOWNER/HOUSEHOLDER/TENANT

IMPORTANT: Please Tick Box to Confirm You Understand! (Required)

I CONFIRM I UNDERSTAND THAT NO PERSONAL CARE IS PROVIDED UNDER THE SUPPORTMATCH GUARDIANSHIP SCHEME

PROPERTY GUARDIANS DO NOT PROVIDE OVERNIGHT ATTENDANCE SUPPORT OR PERSONAL CARE OF ANY KIND. HOWEVER, IN EXCHANGE FOR AFFORDABLE ACCOMMODATION YOU OFFER TO A GUARDIAN; WILL OFFER UP TO 3 HOURS PER WEEK OF PRACTICAL SUPPORT AND/OR COMPANIONSHIP.

If you have any questions or concerns please call 0203 633 6066 to discuss this with a Supportmatch Homeshare Coordinator.

Property Guardian Room Occupancy Preference (Required)

SINGLE PERSON
COUPLE
NO PREFERENCE

What is the Type/Size of the Accommodation you are offering (Required)

SINGLE ROOM
DOUBLE ROOM
SELF-CONTAINED ACCOMMODATION

Bathroom Facilities Offered (Required)

SHARED BATHROOM
EN-SUITE BATHROOM

How Many Rooms would you like to offer (Required)

Each room will generate a fixed monthly income for you the Homeowner. The Homeowner instructs us on how much they would like to receive each month for each room.

How much would you like to charge each month for the accommodation you are offering. (Required)

Each room you offer will generate a fixed monthly income. The Homeowner instructs us as to the amount they would like to charge the Guardian.

Note: We will add an 18% Service Fee to the amount you would like to receive and pass on this cost to the Guardian.

You will receive the amount agreed upon for the accommodation you offer.

WHEN WOULD YOU LIKE THE ACCOMMODATION OCCUPIED AND EARNING YOU A MONTHLY INCOME (Required)

ASAP
WITHIN 1 MONTH
WITHIN 3 MONTHS
FLEXIBLE

CONDITION OF THE ACCOMMODATION OFFERED (Required)

EXCELLENT READY TO MOVE INTO
VERY GOOD READY TO MOVE INTO
NEEDS A LITTLE PREPARATION BEFORE MOVE IN
SIGNIFICANT PREPARATION REQUIRED

BRIEFLY DESCRIBE THE ACCOMMODATION YOU ARE OFFERING TO A PROPERTY GUARDIAN (Required)

OPTIONAL: YOU CAN UPLOAD UP TO 5 PHOTOS OF THE SPARE ROOM

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

This is entirely optional but very much helps when we discuss and describe the options you as a Householder will offer to potential property Guardians.

HOT WATER & HEATING IS IN GOOD WORKING ORDER (Required)

YES
NO

ISSUES WITH MOULD OR DAMP (Required)

YES
NO

ISSUES WITH KNOWN VERMIN INFESTATION (Required)

YES
NO

DOES THE PROPERTY HAVE INTERNET ACCESS (Required)

YES
NO

ABOUT YOUR INTERESTS AND ROUTINES

Please Tell Us About yourself; Your Interests, Hobbies, Personality, Likes, Dislikes and Preferences in General (Required)

This section is important and will greatly help us to determine the Kind of Guardianship Candidates that best fit in with your interests, personality and general nature.

We will refine the requirements and your preferences during your initial telephone assessment with a Supportmatch Manager.

Please Briefly Describe Your Daily Routine (Required)

This section is important and will greatly help us refine the list of suitable Guardian candidates that best fit your requirements.

DO YOU HAVE ANY PETS

YES
NO

WHAT SORT OF PET(S) DO YOU HAVE

WOULD YOU MIND SHARING WITH SOMEONE WITH A PET (Required)

NO (OTHER) PETS ALLOWED
I DONT MIND ALLOW A PET
IT DEPENDS

HOUSEHOLDER PROPERTY ASSESSMENT

This Assessment ensures that you are able to accommodate a Homeshare who will provide you with Support and Companionship.

DOES THE PROPERTY HAVE ANY OF THE FOLLOWING

PLEASE DISCLOSE ANY POTENTIAL RISKS TO HEALTH & SAFETY THAT YOU WOULD LIKE TO SHARE WITH US

Skip this question if you have nothing further to add.

QUALITIES IN THE GUARDIAN CANDIDATE YOU ARE LOOKING FOR

I PREFER THE HOMESHARER TO BE (Required)

Male
Female
Couple
No Preference

ARE YOU A SMOKER (Required)

Yes
No

COULD YOU LIVE WITH A SMOKER (Required)

Yes
No
It Depends

PLEASE TELL US ABOUT ANY OTHER QUALITIES YOU ARE LOOKING FOR IN A GUARDIAN (Required)

HOUSEHOLDERS ACKNOWLEDGEMENT & AGREEMENT

TERMS & CONDITIONS OF REGISTRATION (Required)

I AGREE WITH THE TERMS & CONDITIONS OF MY APPLICATION

1. To Supportmatch Homeshare Householder Terms & Conditions as Set Out in my Application.

2. To Allow Supportmatch Homeshare to Record my Personal Data and Information, for the Purposes of Facilitating and Delivering the Supportmatch Homeshare Services, which includes Matching, Monitoring and Oversight Services Provided throughout the duration of a Homeshare Arrangement following a Successful Match with a Suitable Homesharer Chosen by You the Householder.

3. I Confirm that the Information I have provided in my Application is Accurate.

INFORMATION: TO VIEW THE TERMS & CONDITIONS OF SERVICE PLEASE GO TO THE TOP OF YOUR APPLICATION AND CLICK THE LINK HOUSEHOLDER TERMS & CONDITIONS.

Householder/NOK Signature

Clear Signature

GUARDIANSHIP HOMEOWNER APPLICATION FORM

HOMEOWNER/HOUSEHOLDER PERSONAL INFORMATION

HOMEOWNER/ HOUSEHOLDERS FULL NAME

EMERGENCY CONTACT OR NEXT OF KIN (NOK)

CONTACT & POWER OF ATTORNEY INFORMATION

ACCOMMODATION/SPAREROOM OFFERED BY HOMEOWNER/HOUSEHOLDER/TENANT

PROPERTY GUARDIANS DO NOT PROVIDE OVERNIGHT ATTENDANCE SUPPORT OR PERSONAL CARE OF ANY KIND. HOWEVER, IN EXCHANGE FOR AFFORDABLE ACCOMMODATION YOU OFFER TO A GUARDIAN; WILL OFFER UP TO 3 HOURS PER WEEK OF PRACTICAL SUPPORT AND/OR COMPANIONSHIP.

ABOUT YOUR INTERESTS AND ROUTINES

HOUSEHOLDER PROPERTY ASSESSMENT

DOES THE PROPERTY HAVE ANY OF THE FOLLOWING

QUALITIES IN THE GUARDIAN CANDIDATE YOU ARE LOOKING FOR

HOUSEHOLDERS ACKNOWLEDGEMENT & AGREEMENT

This field can be left blank if you are unable to use your device to physically sign your application.