Child Benefit Self Declaration

Energy Company Obligation (ECO4) Child Benefit Self-Declaration
Address Line 1*
Address Line 2
Address Line 3

Street Address Line 2

TownState / Province

Postal / Zip Code
Town/City*
Post Code*
I, the occupier of the premises detailed above, declare that I am in receipt of Child Benefit and that for the corresponding number of qualifying children or young persons within this benefit the single or combined annual gross income (before tax and national insurance) threshold detailed in the table above is not breached.

I confirm that the information contained in this form is true and accurate.
Name *
Date*

DayMonthYear
Signature*

Clear
National Insurance Number*
Should be Empty: