APPLICATION FORM

FOR OFFICE USE ONLY

Date of application:

Reference no.

Introduction:
You are about to complete an application for one of DCI CHS rental units. In order for us to process your
application as speedy as possible, please ensure that all requested information (incl. Supporting documents
as listed below) is included in this application and submitted to the DCI CHS Head office.
If you require assistance filling in this application form, please call us at 066 5710251 info@dcichs.co.za
Supporting Documents: Current Payslip (not older than 3 months)
Identity document of applicant
Identity document of spouse (if app)
Married or Divorce or Death certificate (where app)
Birth Certificates of dependents
Affidavits (if app)
Bank statement (past 3 months)

A. Personal Particulars:
Applicant Partner
Surname:
Masiu
First Name: Betsie
Date of Birth:
18/01/1987
Identity Number: 8 7 0 1 1 8. 0 4 0 4 0 8 4
Nationality: South Afrcan
City/Postal code: 7100
(H) Telephone: code number
27 738589270
 Cell phone: code number
277 38589270
Current
Employer:
Robin Trust

Occupation: Carer
Employer’s Oude Molen Eco Village
Address: Alexandra Road Pinelands
(W) Telephone: code Number

021 447156
Length of service:

B. Household Composition:
Single Couple with child(ren)
✓
Couple (married or otherwise) Single parent with child(ren)

Name Date of Birth Relationship

(eg. Child)
1. 2D 4D 0 M8 M1 Y6 Y
Zano Masiu Child
2. 0D 7D 0 M4 M 2 Y3 Y
David Masiu Child
3. D D M M Y Y

4. D D M M Y Y

5. D D M M Y Y

6. D D M M Y Y

C. RESIDENCY HISTORY
Please list your residential address(es) for the past 2 years.
Address: From To Date Landlord Name Landlord Number

32 Kei River 2022 Belinda 0738589270

Indicate your current housing situation

Applicant Partner
Home owner Home owner

Living with family Living with family

Rental apartment or house ✓ Rental apartment or house

Informal Informal

If renting, indicate basic rent per month: R 5000

D. Income Particulars
 Applicant Partner
formal labour formal labour
✓
informal trade informal trade

Pension pension

disability grant disability grant

maintenance grant maintenance grant

other (please specify) ... other (please specify) ...

(List gross monthly income [before deductions] for all members of your household, age 19 and older, from
all sources)
Name Source (Employment, pension etc.) Gross monthly income

Betsie Employment R9000.00

Total Gross Monthly Income for household R 9000.00

E. House Type
1 Bedroom Unit Ground Floor

2 Bedroom Unit ✓ 1st Floor

Bachelor Unit 2nd Floor

✓

F. Marketing and PR
(How did you hear about DCI CHS?)
Newspaper
Radio
Friend / Relative ✓
Other (specify)

G. Signature
I declare that I have read this form carefully and that all particulars are true and correct. Furthermore, I
grant DCI Community Housing Services the right to perform a credit check to assess my credit worthiness.
 Applicant Partner
Place Place
Home
Date Date
22,07,2024
Signature Signature

Received By:
For Office Use Only:
(an application can not be accepted without all Date:
supporting documents attached)