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CALL TODAY: 0333 3202 300
APPLICATION FORM
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Step 3
Enter Your Postcode
What is your current home status?
Home owner
Private Tenant
Are you or ANYONE IN THE HOUSEHOLD OVER 16 currently in receipt of any of the following:
YOU MUST BE IN RECEIPT OF ONE OF THE BENEFITS BELOW TO QUALIFY FOR A FUNDED BOILER
(Please tick all that apply)
Child Tax Credit
Income Based ESA
Income Based JSA
Income Support
Pension Credit
Working Tax Credit
Pension Credit Guarantee Credit Element
Income-related Employment and Support Allowance (ESA)
Income-based Jobseeker's Allowance (JSA)
Income Support
Working Tax Credit
Child Tax Credit
Armed Forces Independence Payment (AFIP)
Attendance Allowance
Carer's Allowance
Disability Living Allowance (DLA)
Severe Disablement Allowance
War Pensions Mobility Supplement
Industrial Injuries Disablement Benefit
Personal Independence Payment (PIP)
Constant Attendance Allowance
Universal Credit
Child Benefit
Do you or anyone in your household claim any of the benefits above?
pick one!
YES
NO
Property type
Detached
Semi-Detatched
End-terraced
Mid-terraced
Flat
Cottage
Number of Bedrooms in your property
1
2
3
4
5+
How old is the boiler
pick one!
1-5 Years
5-10 Years
10 Years +
When was your property built
Before 1920
1920 -1995
10 Years +
What is the main fuel that heats the property?
Mains gas
Oil
LPG
Electric storage heaters
Solid fuel
Unsure
Full Name
Best Contact Number
Mobile Number
(We will use this to give you application updates by text message)
Email Address
First Line of your address
Town
Submit Application
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