Birmingham City Council Flex for ECO3 Grant Form

Birmingham City Council
Application for an ECO LA-Flex Declaration
Full Name *
Address (Line 1) *
Address (Line 2)
Postcode *
Phone *
E-mail
2. Tenure *

Owner Occupier Private Tenant
(a) Net earnings (after tax and NI)
(b) Income from savings and investments
(c) Income from pensions
(d) Income from benefits (including housing benefit)
(e)Total Income (a + b + c + d) *
(h)Council Tax payments (annual)
(i) Mortgage or Rent payments (annual)
(j) Total Outgoing (h + i)
Disposable Income (e – j) *
Is the household annual disposable income above or below the amount below (tick one)?

Below £27,200 Above £27,200
Is the household savings below the amount below (tick one)?

Single person househo (£8,000) More than one-person household (£12,000)
Does the household contain a person who has any of the following health conditions or meets the additional vulnerability criteria (tick all that apply)?

Chronic Respiratory Condition e.g. COPD / Asthma / Pneumonia Diabetes Cardiovascular condition e.g. Coronary Heart Disease, high blood pressure, stroke, heart attack, poor circulatio Cancer Mental Health Condition Musculoskeletal conditions (Osteoarthritis, Rheumatoid Arthritis etc.) Long Term Illness made worse in Winter (i.e. Arthritis) Blood conditions e.g. Sickle Cell Anaemia Disability or Restricted Mobility Neurological Condition (including dementia, Parkinson’s Disease, multiple sclerosis, epilepsy etc.) Aged 60 years or over Pregnant Child under the age of 5 years
I am the applicant and the information provided above is correct. I authorise the Local Authority to make checks with the DWP, HMRC and NHS to verify the information I have provided above.
Signed *

Clear
Full Name *
Date *

Day Month Year
Date
The Council primarily use your data for processing your application. All information is processed in accordance with our organisational data protection policy, which is available on our website. We never sell your data to third parties or use it for marketing purposes without your consent.
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