Direct Debit Support

Direct Debit Support
Direct Debit Fuel Bill Relief Referral Form
Referrers Details
Your Organisation
Your Name*
Your Telephone*
Your email*
example@example.com
Date of Submission

DayMonthYear
Date
By completing the form below you confirm your client has granted you permission to enter their personal data, and for us to speak to them or leave a message. Information on this form will be held and used by Energy Projects Plus for the purposes of providing the assistance requested. This information will not be given to other agencies without your client’s prior approval. Any information provided will be held and used in accordance with the General Data Protection Regulation. Our Privacy Policy can be accessed here.
Client Details
Full name*

First NameLast Name
Address*
Town & Locality
Post Code*
Local Authority*
Telephone*
Alternative Telephone
Email
example@example.com
Number of Children
Number of Adults aged 65+
Number of working-age adults
What is your usual monthly payment amount for energy usage?
Award required for

Gas OnlyElectricity OnlyBoth
Electricity Account Details, (if known)
Electricity Supplier Name
Reference/Account Number
Bank Name
Bank Sort Code
Bank Account Number
Gas Account Details, (if known)
Gas Supplier Name
Reference/Account Number
Bank Name
Bank Sort Code
Bank Account Number
Energy Projects Plus makes at least three attempts to contact each new client. Once we’ve spoken with your client, we will process an application for a fuel voucher if appropriate. Please note, it can take approximately 24 hours for a fuel voucher to arrive from that point. For help completing this form, or if you have any other queries, call the Save Energy Advice Line free on 0800 043 0151. Lines are open 9am-5pm, Monday-Friday
(apart from bank holidays)
File Upload if required. Please upload a copy of your client’s energy bill here, if available, showing their account number.

Cancelof
Email
example@example.com
Should be Empty:

Direct Debit Support

Referrers Details

Client Details

Electricity Account Details, (if known)

Gas Account Details, (if known)