ESN EST Form

Consent form for sharing data with the Energy Saving Trust

This is a quick, simple, and safe way to help us collect some details about you and assess your claim for free funding. You will be emailed a copy of this form after completion.
Name of person completing this form
Type of applicant*

Benefit recipientHousehold vulnerable GP routeHousehold income below £31,000Other
Main applicants details *

First NameLast Name
Date of birth*

DayMonthYear
You must be aged 18 and over to apply
Second applicants details

First NameLast Name
Date of birth - only complete if name showing on benefits

DayMonthYear
You must be aged 18 and over to apply
Applicants address*
e.g Flat 10, 333 Freeman St, Warwick, Warwickshire
Post code*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Best time to contact you?*

9am - 12pm12pm - 3pm3pm - 6pmOther
Property details*

I am a homeownerI am a private tenantI am a landlord or agentI am living with the homeownerI am a social housing or council tenant
Landlord/Agent contact name?*
Landlord/Agent email*
Please provide an email address and we will send an email introduction requesting permission to help lower energy costs.
Landlord/Agent contact number*
Property type*

FlatBungalowMaisonetteDetached houseSemi detached houseEnd terrace houseMid terrace housePark home/chaletOther
Select current main heating type*

No main heating sourceElectric boilerElectric storage heatersElectric underfloor heatingElectric room/panel heatersGas combi boilerGas back boilerGas room heatersGas warm air boilerGas condensing boilerGas non condensing boilerOil heatingLPG heatingCoal/wood logsSolid fossil fuelUnknownOther
Select main qualifying entitlements*

Household vulnerable GP letterHousehold income below is £31,000Income SupportHousing BenefitUniversal CreditsChild Tax CreditsWorking Tax CreditsPension Savings CreditIncome Based Jobseekers AllowancePension Credit Guaranteed Credit ElementIncome Related Employment & Support AllowanceChild Benefit (Income thresholds apply & proof of income will be needed)Other
Insert local authority*
Select how many adults & children living in the household*

1 Adult 0 Children2 Adults 0 Children1 Adult 1 Child2 Adult 1 Child1 Adult 2 Children2 Adult 2 Children1 Adult 3+ Children2 Adult 3+ ChildrenOther
Select annual household Income*

Under £15,000£15,000 - £31,000Over £31,000
Select any vulnerabilities in the household*

Limited mobilityA respiratory diseaseA cardiovascular conditionImmunosuppression conditionPregnantChild under 5 years of ageAdult aged over 60 years of ageNone of the aboveOther
What energy saving measures are you interested in?

All possible grants to lower energy billsInsulationAir source heat pumpsFirst time central heatingHigh retention storage heaters & solar pvBoiler replacement (Non condensing, back boilers, warm air boilers & insufficient below 96% only)
Where did you hear about us?*

Energy saving partnerLandlord or agentWord of mouthSocial mediaWebsiteGoogleOther
Additional Information
Please provide any additional information to help support your claim for free funding
Signature*

Clear
Please sign using your finger, mouse or touch screen pen.
Date

DayMonthYear
Date
Please ensure you upload clear photos of all pages, capturing all four corners. Please send one valid proof of your address and one proof of your benefits from the images provided above.

Incomplete or outdated data may result in funding applications being denied. Your information helps ensure that those who truly qualify receive the support they need.
Cancelof
Please submit a valid proof of your address and proof of your Universal Credit using the images provided above.

Incomplete or outdated data may result in funding applications being denied. Your information helps ensure that those who truly qualify receive the support they need.
Cancelof
Please ensure you upload clear photos of all pages, capturing all four corners. Please send a council tax letter, one valid proof of address and two proofs of income shown from the image provided above e.g. x2 adults = x4 proofs of income to prove income is below £31,000.

Incomplete or outdated data may result in funding applications being denied. Your information helps ensure that those who truly qualify receive the support they need.
Cancelof
Please upload signed GP letter and a valid proof of address from the image provided above*

Incomplete or outdated data may result in funding applications being denied. Your information helps ensure that those who truly qualify receive the support they need.
Cancelof
I/The applicant agree to my information provided (above) being shared with the Department for Work and Pensions via the Energy Saving Trust to confirm whether I am in receipt of the relevant criteria to be eligible for the ECO4 scheme.*

I Agree
We respect your privacy and the privacy of your data. The information you supply is fully encrypted, securely stored, and used strictly in with the terms of our privacy policy.

We are registered with the ICO under the data protection register.

Energy Saving Trust Datamatch service for ECO4 https://datamatch.est.org.uk

Effective from 1 April 2022
Should be Empty: