Warm Home Discount Scheme
1st August 2016 to 31st May 2017

Email Address
Account Number


Tel No

Confirm Email Address





Postcode
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Town
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Address
Name

Yes

No
Do you have electricity with First Utility?


Title

Forename

Surname
In order to register your interest in the Warm Home Discount Scheme, please answer either 'Yes' or 'No' to all questions below by selecting the applicable bubble:
Do you (Or Partner) receive Pension Credit with Savings only?

Yes

No
Do you (Or Partner) receive Income Based Jobseekers Allowance (JSA)?

Yes

No

Yes

No
Do you (Or Partner) receive Income Related Employment and Support Allowance (ESA) which includes a Work Related Activity or Support component?

Yes

No
Do you (Or Partner) receive Income Support?

Yes

No
Are you (Or Partner) in receipt of Universal Credit and are either not in work or are self-employed?

Yes

No
Is your Gross Annual Household Income (Before tax and deductions) less than £16,190?
Are you (Or Partner) aged 60 or over (born on or before 5th April 1956)?

Yes

No
Does your household have parental responsibility for a child aged 18 or under living with you who is in full time education?

Yes

No

Yes

No
Does your household have parental responsibility for a child aged 5 years or under?

Yes

No
Are you in receipt of a work related activity or support component to your ESA?

Yes

No
Are you (Or Partner) in receipt of a Disability Premium as part of your benefit?

Yes

No
Are you (Or Partner) in receipt of a Pensioner Premium as part of your benefit?

Yes

No
Are you (Or Partner) in receipt of a Carer's premium?

Yes

No
Do you (Or Partner) receive Personal Independence Payment, Disability Living Allowance,  Attendance Allowance or Incapacity Benefit for yourself or for another adult or child living with you?
Do you receive exemption from NHS prescription charges because you have on-going or chronic illness?

Yes

No
Are you registered disabled?

Yes

No

Yes

No
Are you living with a mental or physical disability or illness?
Are you (Or Partner) in receipt of a Disabled Child Element?

Yes

No
Are you (Or Partner) in receipt of the Limited Capability for Work element, with or without a Work-Related Activity element?

Yes

No

Agent Id

Date
I agree to First Utility Ltd asking the Department for Work and Pensions (DWP) to confirm whether I am in receipt of a qualifying benefit


Declaration
I understand that you may need to check that I am eligible for the Warm Home Discount Scheme:
I can write to First Utility Ltd at any time to withdraw my consent, but this will result in my withdrawal from the scheme.
I understand that:

- If the Department for Work and Pensions cannot confirm that I receive the qualifying benefits to be eligible to receive the discount I may need to send First Utility Ltd (or an organisation working on their behalf) copies of my benefit letters and other appropriate proof of eligibility.
- If I change my supplier before my discount is paid I will no longer be eligible.

Yes

No
I agree to (First Utility) sharing my details with the Department for Energy and Climate Change and their appointed contractors to undertake research on people's historical experiences of claiming the Warm Home Discount (which will include historical analysis of energy consumption data and whether individuals are successful in their applications).
Yes
I confirm that I have verified the answers provided by checking the appropriate documents provided as evidence.



Name

Agency
I declare that I have assisted this customer to make an application.


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First Utility Limited
Registered in England & Wales: No 05070887.
Point 3 ,Opus 40 Business Park, Haywood Road, Warwick CV34 5AH.
first-utility.com