Declaration in Respect of a Fit and Proper Person

Housing Act 2004 (Part 2 / Part 3)

Name………………………………………………………………………

In connection with the application dated ………………… for a property licence in respect of: ……………………………………………………..............................................................................................
……………………………………………………..............................................................................................
……………………………………………………..............................................................................................
……………………………………………………................................................................(Property Address)

I hereby declare that I am:

(i)	the proposed licence holder
(ii)	the manager of the property to whom rent is paid (if different from (i) above)
(iii)	someone who is otherwise engaged in the management of the property 
(delete as appropriate) 

and that I am a fit and proper person to be engaged in that capacity.

In support of the above declaration I confirm that I:

•	do not have any unspent convictions particularly in respect of any offence involving fraud or other dishonesty, or violence or drugs, or any offence listed in Schedule 3, of Sexual Offences Act 2003;

•	have not been found guilty by any court or tribunal of practising unlawful discrimination on grounds of sex, colour, race, ethnic or national origins or disability in, or in connection with, the carrying on of any business;

•	have not had any judgements (whether civil or criminal) made against me under housing, public health, environmental health or landlord and tenant law.
	
Please provide information about any HMO or house the proposed licence holder or manager owns or manages or has owned or managed which has been the subject of:

•	any appropriate enforcement action described in section 5(2) of the Act;
•	refusal to grant a licence under Part 2 or 3 of the Act, or has had a licence revoked as a consequence of breaching the conditions of his licence;
•	an interim or final management order under the Act

Details of above……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
Read our policy statement and our property licensing and enforcement privacy notice to see what we do with your personal information.

Please note that it is a criminal offence to knowingly supply information which is false or misleading for the purposes of obtaining a licence. Evidence of any statements made in this application with regard to the property concerned may be required at a later date. If we subsequently discover something which is relevant and which you should have disclosed, or which has been incorrectly stated or described, your licence may be revoked or other action taken.

Signed: 							Date:
	
Name: