Affordable Warmth Application

Application text goes here...

 

1. About You
Title:
First name: Surname:
Address:
Postcode:
Telephone No.:
*Email: *A valid email address MUST be entered here.
   

 

2. About Your Benefits - Part 1
Would you like us to check what benefits you are entitled to?
 
  Date of Birth (dd/mm/yyyy):
  Do you own your home or rent it from a private landlord?
 
   
  If you rent your home from a Private Landlord please provide their full name, address and phone number. (We cannot process your application without this information)
Address:
Postcode:
Telephone No.:
   

 

3. About Your Benefits - Part 2
What benefits do you receive? (Please tick all the benefits you recieve)
Working Tax Credit
(with an income of less than £16,200 and which must include a disability element)
Child Tax Credit
(with an income of less than £16,200)
Attendance Allowance
Disability Living Allowance
Income Support
(which must include a disability premium)
Housing Benefit
( which must include a disability premium)
War Disablement Pension
(which must include the mobility supplement or constant attendance allowance)
Industrial Injuries Disablement Benefit
(which must include constant attendance allowance)
Council Tax Benefit
(which must include a disability premium)
   
I have a child under 16, or I am pregnant and have a maternity certificate MAT B1 and receive:
Income Support Council Tax Benefit
Housing Benefit Income Based Jobseeker's Allowance
Your youngest child’s date of birth (dd/mm/yyyy):
   
I am 60 or over and receive:
Pension Credit Council Tax Benefit
Housing Benefit Income Based Jobseeker's Allowance
   
Third Party Contact Details (Tel No.):

 

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