Applicant's details:

Title:

First name:

Surname:

Phone no:

Best contact time:

Email address:

DOB:

(dd/mm/yyyy)

I am applying:

for myself

on behalf of someone else

Applicant's address:

Flat no:

House no / name:

Address 1:

Address 2:

Town / City:

Post Code:

Tenure:

Owner / Occupier

Private / Rented

Please tick one box

Householders aged 60 or over in receipt of one or more of the following benefits:

	Income Support
	Council Tax Benefit (not single occupancy discount)
	Housing Benefit
	Job Seekers Allowance (income-based)
	Pension Credit

Pregnant householders with maternity certificate MAT-B1, tick here:
Householders with a child under 16, enter DOB of youngest child:	(dd/mm/yyyy)
In receipt of one or more of the following benefits:

	Income Support
	Council Tax Benefit (not single occupancy discount)
	Housing Benefit
	Job Seekers Allowance (income-based)
	Pension Credit
Householders in receipt of one or more of the following benefits:
	Working Tax Credit (with an income of less than £15,460, which must include a disability element)
	Disability Living Allowance (not child DLA)
	Child Tax Credit (with an income of less than £15,460)

DOB of youngest child:

(dd/mm/yyyy)

	Housing Benefit (which must include a disability premium)
	Income Support (which must include a disability premium)
	Council Tax Benefit (which must include a disability premium)
	War Disablement Pension (which must include a mobility supplement or Constant Attendance Allowance)
	Industrial Injuries Disablement Benefit (which must include a mobility supplement or Constant Attendance Allowance)
	Attendance Allowance

Which type of property do you live in ?
	House
	Bungalow
	Flat
	Maisonette
	Other
Is your house attached, detached, or semi detached ?
	Attached
	Detached
	Semi detached
How many bedrooms does your property have ?
	1
	2
	3
	4+
What type of heating do you have ?
Approximately what year was your house built?

Do you have cavity wall insulation?
	I would like (if it can be done)
	Don't want
	Already done
	Not technically possible
Do you have full loft insulation ?
	I would like (if it can be done)
	Don't want
	Already done
	Not technically possible
Do you have heating?

nic eic

Corgi Reg. No. 187602 | Company Reg No. 4476739 | Site maintained by Allcomm