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8
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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)
NO (You qualify for the grant)
YES (You do not qualify for this grant)
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2
Is someone in the house in receipt of benefits? if yes, please specify
*
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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
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
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3
Name
*
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First Name
Last Name
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4
Door Number
*
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5
Street name
*
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6
Post Code
*
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7
Phone Number
*
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8
How do you currently heat your home?
*
This field is required.
Electric room heaters
Gas fires
Boiler & Radiators
Other
None
Electric room heaters
Gas fires
Boiler & Radiators
Other
None
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9
type of lead
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