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Assessment Form

Find out if you qualify for a grant BEFORE you pay.

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Part A

All fields marked * are required. You must answer all questions in Part A, B and C in order for us to assess your eligibility. Failure to answer any question may delay your assessment.

Title *
    If Other:

Name *

Address *

Postcode *


Your Email *

Address for the Gas Supply *

Postcode *


Please check the appropriate box for each question in Part A

1. Do you live at the gas supply address?
 Yes No (You must live at the house to claim a grant)

2. Are you currently:

Building your house
 Yes No

Renovating your house
 Yes No

3. Are you:

A. the property owner?
 Yes No (If yes, please provide evidence of ownership)

B. an occupier of the property? (you live in home but do not own or rent it)
 Yes No (If yes, please provide evidence of residency)

C. a private tenant?
 Yes No (If yes, please provide evidence of tenancy agreement)

D. the tenant of a housing association or local authority?
 Yes No (If yes, please provide evidence of tenancy agreement)

(if yes - please select a copy of a requested document to upload)

For tenants: please provide Landlord’s Name/Address/Telephone number in the box below:


Correspondence Address


4. How many people (including children) in your household?

Number of Male adults and their ages

Number of Female adults and their ages

Number of Children and their ages

5. Is anyone usually at home during the day?
 Yes No

6.a. What is the yearly combined income, after tax of the people living in your home? (Please include all wages, benefits, pensions, and any interest on savings – after tax and any National Insurance payments.)
Income – after tax: Week, or month or year

Each Week £

Each Month £

Each Year £

6.b.What are your housing costs and do you receive any help to pay your housing bills?

Housing costs each year

Mortgage £

Rent £

Council Tax £

Housing help each year

Mortgage support £

Housing Benefit £

Council Tax Reduction £

7. Please explain if:

Your surname differs from the name on your evidence

Your address differs from the address on your evidence

8.a. How do you pay for your household energy?
 Quarterly Direct Debit Pre-payment

8.b. How much do you pay for your household energy in a year?

Select your Existing Fuel

If your fuel is Economy 7 please give cost of Day and Night units
Unit cost day £
Unit cost night £

Standing charge each year (if this applies)

Cost per kWh \ litre \ tonne

Part B

Statement of Benefits

Where do you live?
 England Wales

Your benefits

Please check each box if you claim any of the following benefits:

 Pension Credit Income Based Job Seeker’s Allowance Working Tax Credit (an Upper Earnings Limit applies) Child Tax Credit (an Upper Earnings Limit applies) Income Related Employment and Support Allowance Income Support Council Tax Reduction (for Wales residents only) Universal Credit (for Wales residents only)

Your husband's, wife's or partner's benefits (Wales only)

Please check each box if your partner claims any of the following benefits (Wales only):

 Pension Credit Income Based Job Seeker’s Allowance Working Tax Credit (an Upper Earnings Limit applies) Child Tax Credit (an Upper Earnings Limit applies) Income Related Employment and Support Allowance Income Support Council Tax Reduction Universal Credit

(Copies of your benefit award letters will be required, please select a file to upload)

Part C

1. When was your home built?
 Pre 1900 1900-1929 1930-1949 1950-1966 1967-1975 1976-1982 1983-1990 1991-1995 1996-2002 2003-2006 Post 2007

2. What type of home do you have?
 House Bungalow Flat Maisonette

3. Is your home:
 Detached Semi-detached End terrace Mid-terrace Flat

4. Floor Level (for flats and maisonettes only)
 Top floor Mid floor Ground level Basement

5. How many storeys does your home have:

6. How many bedrooms in the property:

7. How many living/dining rooms in the property:

8. How much of your home is double glazed:
 None Some (up to 25%) Half (50%) Most (75%) All (100%)

9. Are your window frames made of:
 Wood Plastic / UPVC Metal

10. What type of roof does your home have?
 Flat Pitched - No Access Pitched Roof Pitched (Thatch) Pitched / Loft Access Another Dwelling Above

11. What is the depth of loft insulation?
 ½”/12mm 1”/25mm 2”/50mm 2.5”/75mm 4”/100mm 6”/150mm 8”/200mm 10”/250mm 12”/300mm 12+”/300mm+ Flat roof insulation None Unknown

12. Are your external walls:
 Solid Brick Cavity Timber Frame Concrete Stone Other

(if other please specify)

13. What wall insulation do you have:
 No Insulation Filled Cavity Insulation Internal Wall Insulation Unknown As Built External Insulation

Part D

1. What is your main heating system in your home?
 Standard Boiler Warm Air System Condensing Boiler Storage Heaters Combi Boiler Room Heaters / Fires Condensing - Combi Boiler Other

If 'Other' please specify:


2. What fuel does your main heating system use?
 Anthracite Coal (open fire in grate) Coal (closed room heaters) Wood chips Wood logs Wood pellets (bulk supply) LPG/Bottled gas LPG Bulk (Tank) Heating oil Electricity – on peak Electricity – off peak (night storage heaters)

3. What controls does your heating system have:
 No controls Heater/Fire thermostat Programmer and Room thermostat Radiator valve thermostat Manual Charge Control Automatic Charge Control

4. If you have a boiler, please specify the make/model number of your boiler:



5. Is your boiler:
 Wall mounted Floor standing Back boiler

Part E

Questions 1 to 5 below refer to how you heat your hot-water in your home:

1. How do you heat your hotwater in your home:
 From main heating system (boiler) From secondary heating Back boiler Electric Immersion (off-peak) Instant Electric water heating Electric Immersion (on-peak)

2. Cylinder size:
 No Cylinder Normal 90 - 130 litres (up to 90cm / 36' tall) Medium 131 - 170 litres (between 90cm / 36' to 135' / 54' tall) Large > 170 litres (over 54' tall) No Access

3. What is your cylinder insulation type:
 No insulation Factory fitted insulation (Solid Foam) Hot Water Tank Jacket

4 What thickness is your cylinder insulation:
 None 12mm 25mm (Factory fitted - yellow) 35mm 38mm 50mm (Factory fitted - Green) 80mm 120mm 160mm

5. Does your cylinder have a Thermostat:
 Yes No

Part F

Do you have any renewable technology in your home?
 Yes No

If yes, please state type:
 Solar PV Solar Thermal Air Source Heat Pump Other

Part G - Wales & West Utilities Ltd quotation details

CRM Ref *:

Quote Value excluding VAT *

Quote Value including VAT *

Date Quotation issued *

Date Quotation valid until *

Please enter these characters in the box below:

By submitting this electronic form I give permission for the information on this form to be used by Integrated Energy Service IES and our partners for the purpose of this project. The information may be recorded by Wales & West Utilities and used for reporting to Office of Gas & Electricity Markets (OFGEM) under the current regulations.

This information will not be given to other companies or agencies and will be held or used in accordance with the Data Protection Act 1998.