Eco4 Flex Eligibilty form NUNEATON

North Warwickshire Borough Council & Nuneaton & Bedworth Borough Council

ECO 4 Flex Resident Assessment Form
Name of representative completing form*
Date*

DayMonthYear
Date
I confirm that to the best of my knowledge, the information provided by the applicant is true and correct and that the household is eligible for Eco Flex.
Lead Gen/Surveyor Signature*

Clear
Applicants name*
Address Line 1, 2 & Town*
Postcode*
Phone*
Email
example@example.com
Tenure*

Owner OccupiedPrivate Tenant
Tenure evidence

Land registryDeeds or mortgage statementIf rented, a tenancy agreement
Existing EPC Rating*

DEFGNo EPC
EPC Certificate Number
Number of adults living in property*
Number of children living in the property*
FLEX Route*

Route 3 - NHS ReferralRoute 1 - less than £31k
Route 1 Evidence provided

Tax returns3 payslips alongside bank statements from the last 3 monthsP45 from last 3 monthsP60 for each job/pensionMost recent annual pension statements
Which energy efficiency measures are being considered for this property (tick all that apply)*

Loft insulationCavity wall insulationGas boilerHeating controlsFirst time central heating
NBBC or NWBC does not endorse any specific ECO provider or contractor. By checking this box, I confirm I want to be informed of future council schemes and services to keep my home warm or improve its energy efficiency.*

I understand that the availability of ECO4 funding and measures will be subject to a retrofit coordinator and thatBy checking this box, I confirm I want to be informed of future council schemes and services to keep my home warm or improve its energy efficiency.
I understand I can withdraw my consent at any time by emailing: Green.homes@nuneatonandbedworth.gov.uk

Signed by Householder
Signature*

Clear
Date

DayMonthYear
Date
Should be Empty: