PUBLIC SERVICE RENTAL SCHEME APPLICATION Form 21

Applicant's Name:*

First

Middle

Last

Ministry:*

Post and Level:

TPF:*

Lease Start Date:

Contact Details:

Phone Number:

Email Address:

Marital Status:

Children

Number of Children:

(Enter their age separated by comma)

Do You or Your Spouse Own Another House in the Same Town Area?

Yes

No

NOTE – if the answer is YES then you are not eligible for PSRS benefits

Spouse’s full Maiden Name:

Does a Landlord and Tenant Conflict of Interest Exist? Acting as landlord and tenant Renting from a spouse

Yes

No

NOTE – if the answer is YES then you are not eligible for PSRS benefits

Do You or Your Spouse Live in Government Owned Quarters?

Yes

No

NOTE – if the answer is YES then you are not eligible for PSRS benefits

Do You Receive a Housing Allowance?

Yes

No

NOTE – if the answer is YES then your housing allowance will cease if your PSRS application is approved

Are You Presently Living in a PSRS House?

Yes

No

(If Yes – what is the Location & Parcel Number or Lot Number or GHD Lease Number?)

Location:

Parcel No. or Lot No. or GHD Lease No:

Do You Have a Preference for Where You Want to Live Now?

Yes

No

(If you are not presently living in a PSRS house then enter the location and Parcel Number of your new preference in the next column)

Location:

Parcel No. or Lot No. or GHD Lease No:

Asking Rental:

Amount in SBD

Other Relevant Details (if any):

Use the upload button below should there be attachments

Applicant's Signature:

Landlord’s Bank Details:

Account Name:

Account Number:

Bank Name:

Date Form Submitted:

Are you human?*