Cold to Cosy Homes application

Surname*

First Name*

Title

Address line 1*

Address line 2

Town*

Postcode*

Local Area*

Primary Contact Number*

Secondary Contact Number

Date of Birth*

Is there anyone (e.g. a carer or relative) who should be the primary contact used to arrange the call/visit?
If yes, please enter their details below (please note that our team will need to speak briefly to the named applicant to check consent for someone else to speak on their behalf)

Alternative Contact Name

Alternative Contact relationship to you

Alternative Contact Home Number

Alternative Contact Mobile Number

Alternative Contact Email Address

Best time to contact you (AM/PM/ANYTIME)*

Occupancy*

Housing Association (if relevant)

Is your gross household income below £31,000?*

Are you or anyone in your household currently receiving benefits?*

Do you or anyone in your household have a health condition worsened by cold weather, damp or mold?*

Are you or anyone in your household 65yrs or above?*

Do you or anyone in your household meet any of our vulnerability criteria listed below?*

Other details regarding health or eligibility

If you are a homeowner, is your gas central heating broken?*

How did you hear about us / our energy advice?*

How did you hear about us - further notes

What are the energy issues you would like advice on? *

Referrer Name*

Referrer Organisation*

Referrer Email*

Referrer Comments*

Please read the following privacy statement to the applicant, then tick the box below to confirm that they agree to sharing their information with us:

You have contacted Cumbria Action for Sustainability to find out if you can benefit from Cold to Cosy Homes Cumbria. We are collecting personal information from you to confirm your eligibility for the scheme, which may include information about your health. You can withdraw your consent at any time by emailing cosyhomes@cafs.org.uk, however if you do withdraw consent or choose not to give us this information, it may make you ineligible for the scheme. If you are relying on the circumstances of another member of your household for eligibility for the scheme we may need to ask them for their information unless they are physically or legally incapable of giving consent. For more information about what Cumbria Action for Sustainability does with your personal information, our privacy notice is available on our website.
Please confirm you have read the above *