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Green Leaf
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Grants Include: *Free A-Rated Combi Boiler *Free Radiators in Every Room *Free Hive Smart Controls *Free MAGNA Clear Water Filter
FULL NAME
EMAIL
ADDRESS
POSTCODE
PHONE NUMBER
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2
Has your property ever had gas central heating before?
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YES
NO
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3
Do you or anyone in the property claim a benefit?
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YES
NO
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4
What type of benefit do you receive?
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Income Based Jobseekers Allowance
Income related Employment & Support Allowance
Income Support
Pension Credit Guarantee
Pension Credit Savings
None
Housing Benefit
Working Tax Credit
Child Tax Credit
Universal Credit
Earning based child benefit
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Please Select
Income Based Jobseekers Allowance
Income related Employment & Support Allowance
Income Support
Pension Credit Guarantee
Pension Credit Savings
None
Housing Benefit
Working Tax Credit
Child Tax Credit
Universal Credit
Earning based child benefit
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5
If you do not claim benefits, do any of these apply?
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1) Total household earnings under 31K gross
2) Health condition including mobility, respiratory, cardiovascular, immunosuppressed
3) None of the above
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Please Select
1) Total household earnings under 31K gross
2) Health condition including mobility, respiratory, cardiovascular, immunosuppressed
3) None of the above
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6
Questions about your property
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Electric Room Heaters
Electric Storage Heaters
Gas Room Heaters
Single Gas Fire
No Heaters
Gas Warm Air System
Electric Warm Air System
Back Boiler Radiators
Oil Boiler Radiators
Solid Fuel Boiler and Radiators
Condensing Gas Boiler & Radiators
Non-condensing Gas Boiler & Radiators
System Gas Boiler & Radiators
Conventional Gas Boiler & Radiators
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Electric Room Heaters
Electric Storage Heaters
Gas Room Heaters
Single Gas Fire
No Heaters
Gas Warm Air System
Electric Warm Air System
Back Boiler Radiators
Oil Boiler Radiators
Solid Fuel Boiler and Radiators
Condensing Gas Boiler & Radiators
Non-condensing Gas Boiler & Radiators
System Gas Boiler & Radiators
Conventional Gas Boiler & Radiators
How is your house currently heated?
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Owned
Private Rented
Council Rented
Social Housing Rented
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Owned
Private Rented
Council Rented
Social Housing Rented
Is your house rented or owned?
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Terraced
Semi-detached
Detached
Bungalow
Flat
Other
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Terraced
Semi-detached
Detached
Bungalow
Flat
Other
What is your house type?
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1
2
3
4
5
6+
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1
2
3
4
5
6+
How many bedrooms does your house have?
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