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Home Energy Grants & Funding Application Form
Applicant Information
Title
Forename*
Surname*
Address line 1 (including name and/or number)*
Address line 2*
Address line 3
Address line 4 (Town)*
Address line 5 (County)*
Postcode*
Local Authority*
Landline or Main Telephone Number*
Mobile or Secondary Telephone No
Email Address (Main)*
What’s your first language?*
Do you need a representative to speak on your behalf?*
Representative Name*
Representative Address
Representative Phone Number*
Representative Email*
What’s your gender?
What’s your ethnic group?
Are you a refugee or asylum seeker?
Are you a military veteran?
Do you feel warm and comfortable at home?
Do you feel happy at home?
Do you understand your energy use and energy bills?
Where did you hear about us?*
Property Information
Please indicate your status as the householder
Landlord name
Landlord address (if known)
Landlord contact number
Landlord email address
What type of building do you live in?
How many bedrooms do you have?
Is your property a listed building?
Is your property in a conservation area?
What type of walls do you have?
Are your walls insulated?
How much loft insulation do you have?
What is the council tax band?
What is the Energy Performance Certificate rating of the property?
What is your current heating system?
What type of fuel does your heating system use?
Is your heating system working?
How old is your heating system?
Who is your electricity supplier, if known?
Who is your gas supplier, if known?
Do you have a smart electricity meter?
Do you have a smart gas meter?
Do you worry about paying for your energy bills?
Do you worry about paying for other bills (for example food)?
Do you have any problems with damp and mould?
Is the property uncomfortably cold or draughty in the Winter?
Is the property uncomfortably warm in the Summer?
Why are you applying for energy saving home improvements?
Financial Information
Does anyone in the household receive any of the following benefits?
If yes, please select from the following:
If you receive more than one benefit, please list them here:
What is the estimated total household annual income (gross – before any income tax or national insurance paid for all residents)?
How much do you spend on your mortgage or rent each year?
Does the household have cash savings of over £10k (including premium bonds and shares)? If no, please enter an approximate amount
Does the household receive a council tax reduction (due to low income)?
Does anyone in the household receive free school meals based on low-income?
Please record the following information:Date of birth of eldest resident
Number of adults (18+)
Number of children under 5
Number of children between 6 and 18?
Does anyone in the household have any health conditions or vulnerabilities?*
If yes, please select from the following
If you have more than one health condition, please list them here
Additional information
Are you happy for us to store this information on our secure database in order for us to review how we can best support you?
Are you happy for us to speak to other people on your behalf?
Would you be happy if we contacted you regarding your experience and to let you know about future funding opportunities if they come up?