|Offaly County Council, |[pic] |
|Áras an Chontae, | |
|Charleville Road, | |
|Tullamore, | |
|Co. Offaly. | |
|Tel No.: 057-9346874 | |
|Fax No.: 057-9329240 | |

HOP 1

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Please read the attached conditions prior to completing this form

All questions must be answered

Please write your answers clearly in block capital letters

Applicant: __________________________________________________________

Address: __________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Telephone No: _________________________ Mobile No: __________________

Date of Birth: _________________________ P.P.S. No: ___________________

Occupation: __________________________________________________________

Name of person for whom grant aid is sought (if different from Applicant):

____________________________________________________________________________

Relationship to applicant: ______________________________________________________

Name of the owner of the property to which the proposed repairs/improvement works are to be carried out:

_____________________________________________________________________________

Gross Annual Household Income: €______________________________________________

(Please refer to explanatory note 3 below)

Is the person for whom the grant is sought residing at the address above: _______________

How long has s/he been living at this address: ______________________________________

Do any of the occupants of the household suffer from any specific illness? If so, please give brief description and complete the attached doctors certificate:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Details of all persons living in property for which grant aid is sought (including applicant):

|Name |Relationship to applicant |Date of birth |Gross Income (previous |Occupation |
| | | |tax year) |(if applicable) |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |

Number and description of rooms in the dwelling:

| |Bedrooms |Living |Dining |Kitchen |Other |
|Upstairs | | | | | |
|Downstairs | | | | | |

General description of proposed works:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Estimated cost of works: € ______________________________

Amount of grant you are applying for: € ______________________________

Balance of costs: € _____________________________

How do you propose to fund the balance of costs: € _____________________________

Has an Essential Repairs Grant, Special Housing Aid for the Elderly Grant or Housing Aid for Older People Grant been paid previously in respect of the same premises or person? If yes, please give details:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Signature of Applicant: ___________________________ Date: _______________________

Completed applications forms should be returned to:

Housing Section, Offaly County Council, Áras an Chontae, Charleville Road, Tullamore, Co. Offaly.
HOP 2
CERTIFICATE OF DOCTOR

HOUSING AID FOR OLDER PEOPLE SCHEME

I hereby certify that the proposed works on the attached application form are necessary for the proper accommodation of:

NAME: ______________________________________________________________

ADDRESS: ______________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

WHO SUFFERS FROM: __________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

NAME OF DOCTOR: ____________________________________________________________

DOCTOR’S STAMP

ADDRESS: ____________________________________

______________________________________________

______________________________________________

______________________________________________

SIGNED: __________________________________________________________________

DATE: __________________________________________________________________

-----------------------

HOUSING AID FOR OLDER PEOPLE

APPLICATION FORM

Works must not commence prior to receipt by the Local Authority of the grant application and written approval from the Local Authority

The person for whom the grant is sought must occupy the house as his/her normal place of residence TH of r
The