Wirral FLEX FORM

Wirral FLEX FORM
1. Organisation/ Company Details
Referrer organisation/company name
Name of representative submitting the form
address
email address
I confirm that to the best of my knowledge, the information provided by the applicant is true and correct and the house hold is eligible for GBIS/ECO4.
Signature from surveyor

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Date
2. Applicant Details
Name

First NameLast Name
Address
Postcode
Email
example@example.com
Phone number
3. Applicant Tenure
applicant tenure

Owner OccupiedPrivate rented
Number of Residents residing at the address
Proposed measures
6. Qualifying route
Qualifying Route

Route 1: Household income less than £31kRoute 3: NHS Referral
Route 3 Proxy
Low Income
For the purpose of identifying households in fuel poverty and those on low income and vulnerable to the cold, low income is determined by gross hosuehold incomeof £31k or less, including any disability benefits.
What is the gross the annual household income?
EPC Band
EPC Rating
Signature of applicant

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Date
Should be Empty:

1. Organisation/ Company Details