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Please tick the relevant boxes:

I own my homeI rent my home

Housing Association tenants do not qualify.

I receive a benefit: YesNo

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Your Details...

Name:

Date of Birth

Email:

Telephone Number:

First Line of your Address:

City:

Post Code

Council Area:

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Your Current Heating System

Please tick the relevant box

NoneSolid FuelBottle Gas (LPG)OilEconomy 7/ElectricGas

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Benefits

Please tick what benefits you're entitled too

Income SupportIncome Related Employment Support AllowanceIncome Based Jobseekers AllowancePension CreditChild Tax Credit (with relevant income less than £15,860)Working Tax CreditDisability Living AllowanceAttendance AllowanceHousing Benefit