FREE CENTRAL HEATING

1
Do you currently have central heating in your home?* This field is required.
NO (You qualify for the grant)
YES (You do not qualify for this grant)
2
Is someone in the house in receipt of benefits? if yes, please specify * This field is required.
Universal Credit
Pension Credit Guarantee Credit Element
Income-related Employment and Support Allowance (ESA)
Income-based Jobseeker’s Allowance (JSA)
Income Support
Working Tax Credits
Child Tax Credits
Armed Forces Independence Payment (AFIP)
Attendance Allowance
Carer’s Allowance
Disability Living Allowance (DLA)
Severe Disablement Allowance
War Pensions Mobility Supplement
Industrial Injuries Disablement Benefit
Personal Independence Payment (PIP)
Constant Attendance Allowance
Child Benefit
Other
3
Name* This field is required.
First Name
Last Name
4
Door Number* This field is required.
5
Street name* This field is required.
6
Post Code* This field is required.
7
Phone Number* This field is required.
8
How do you currently heat your home?* This field is required.
Electric room heaters
Gas fires
Boiler & Radiators
Other
None
9
type of lead
Should be Empty: