Date stamp when received
This form may not be sold or bought.
It is free from the City of Cape Town
APPLICATION FOR HOUSING ASSISTANCE / ACCOMMODATION
FOR OFFICE USE ONLY
Date application form was received Year Month Day
Receiving Housing official’s name
Receiving housing office’s name
Registration number allocated on the database
Existing application date Year Month Day
APPLICANT’S PERSONAL DETAILS (please attach copy of identity book)
Surname
First names
Identity number
(ID Number must be given)
Date of birth
Year Month Day
SPOUSE OR PARTNER’S PERSONAL DETAILS (i.e. wife/husband, not children) (please attach copy of id book)
Surname
First names
Identity number
(ID Number must be given)
Date of birth
Year Month Day
RESIDENTIAL DETAILS (Address where you actually live)
YOUR RESIDENTIAL ADDRESS
Room/Flat number and
name/block or Structure number
Street number and street name
Suburb
Postal code
2nd
1st Cellphone number Cellphone
number
Landline telephone number
If you are resident in an informal settlement what is the settlement’s name
How long have you lived in this settlement?
MARITAL STATUS (Mark with a cross X)
Married in community of property Divorced with dependants
Married by antenuptial contract (out of Separated, or partner deserted,
community of property) with dependants
Single with dependants
Customary marriage or Single without dependants
Muslim marriage
Common law partner Engaged to be married
Widowed
Date Da Date divorced/
Year Month Year Month Day
married y split
DETAILS OF ANY DISABILITY IN THE FAMILY
Full details of any disability or medical
condition in the family
Category Type of disability Degree of disability Tick X
A Walking Walking Aids (e.g. walking aids, walkers, crutches,
walking stick)
B Walking Wheel Chair - partial - Partial Usage
C Walking Wheel Chair - full time usage
D Hearing Partially / profound deaf
E Vision Partial / Totally Blind
F Limited or no use of upper Partial/Total movement loss/paralysis in upper limb
body limbs
INCOME DETAILS OF APPLICANT AND PARTNER (wife and husband)
INCOME PER MONTH INCOME PER WEEK
Applicant (gross wage/salary) R R
Partner (gross wage/salary) R R
Pensioner R R
TYPE OF GRANT AND AMOUNT
TYPE OF GRANT AMOUNT PER MONTH
Maintenance
Child/foster care
War veteran
Disability
Any other regular monthly income
DETAILS OF PRESENT LIVING ACCOMMODATION (Mark with a cross X)
In Main house/flat/hostel with the Wood & iron shack
owner or tenant
Outside room for renting Wendy house
Other - please describe Caravan/vehicle
DETAILS OF PROPERTY OWNERSHIP
Have you or your spouse/partner ever owned property before OR
Yes No
do you or your spouse/partner own property now?
If yes, please give address details
Are you currently a Council tenant? Yes No
If yes, please give address details
DECLARATION:
I declare that all the information given by me above is to the best of my knowledge complete and correct. If
any false declaration is made it will render this application null and void and you will forfeit a housing
opportunity.
Applicant’s signature Date
NOTE: Please include copies of your id book and your spouse/partners id book and marriage or death
certificates.
