Home Owner Gas Connection Application

PART A

Name:*

Address:*

Postcode:*

Telephone:*

Email:*

Do you need us to contact you via different details than those supplied above?*

Yes
No

Correspondence Address:*

Correspondence Postcode:*

Correspondence Telephone:*

Do you live at the gas supply address?*

Yes
No

PLEASE NOTE: 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. Your residency details:

A. Are you the property owner?*

Yes
No

Does your property have an EPC?*

Yes
No

If 'Yes' what is the rating?

B. An occupier of the property (you live in home but do not own or rent it)?*

If answering ‘Yes’, please provide us with evidence of residency.

Yes
No

C. A private tenant?*

Yes
No

D. The tenant of a housing association or local authority?*

Yes
No

Consent Form – What is consent, when is it required and who obtains it?

It is the responsibility of the customer to obtain any required consents and carry out all negotiations. Written proof of consent is required before work can be carried out.

Consent is written permission from a property owner to enter, excavate and install a gas service within their land. It is required when any low pressure service, less than 63mm diameter, crosses third party land. This can include the siting of a meter box or the installing of pipework between the meter and the customer’s appliances.

To be completed by you, the requester of the work:

Your Order Number (if applicable):

Your Name:

Organisation:

House Number:

House Name (if applicable):

Street name:

Town/ City:

Postcode:

Phone (Day):

Phone (Evening):

Email Address:

Consent required from the owner of property:

House Number:

House Name (if applicable):

Street name:

Town/ City:

Postcode:

Please indicate what you require consent for:

Require consent for

The laying of a gas pipe across the private ground

The laying of a gas pipe across the private ground

(and/or)

The installation of a gas meter box on the wall

The installation of a gas meter box on the wall

(and/or)

The laying of gas pipe across the building wall or inside the property

The laying of gas pipe across the building wall or inside the property

To be completed by the consent giver:

Your Name:

Organisation:

House Number:

House Name (if applicable):

Street name:

Town/ City:

Postcode:

I, being the:

Consent giver type

Owner of the property
Acting agent on behalf of the owner of the property
Appointed contractor of the owner of the property

Provide consent for:

Consent – The laying of a gas pipe across the private ground

The laying of a gas pipe across the private ground

(and/or)

Consent – The installation of a gas meter box on the wall

The installation of a gas meter box on the wall

(and/or)

Consent – The installation of a gas meter box on the wall

The installation of a gas meter box on the wall

At property:

House Number:

House Name (if applicable):

Street name:

Town/ City:

Postcode:

Date:

For tenants – please provide Landlord’s details below:

Landlord Address:*

Landlord Postcode:*

Landlord Telephone:*

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

Number of adults living in the property:

Number of children under the age of 14:

Number of children over the age of 14:

6. a. What is the combined income over a year, after any tax and National Insurance is paid, of all the people living in your home? (Please include all wages, benefits, pensions, interest on savings or any other money received – after tax and any National Insurance payments.)

How would you like to enter your income?

By week
By month
By year

Your income each week (after tax):

Your income each month (after tax):

Your income each year (after tax):

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.a. How do you pay for your household energy?*

Quarterly
Direct Debit
Pre-payment

PART B

Statement of Benefits

Your benefits

Please check the box if you or your partner claim any of the following benefits:

Please choose which reference you wish to provide:

National Insurance Number
Benefit reference number

National Insurance Number:*

Benefit reference number:*

If your EPC is E, F or G you will need to meet any TWO of the following (if you meet options 1 and 3 another one must be selected from the list)

1. Home is in Lower Super Output Area (IMD) one to three
2. A householder receives a council tax rebate (Rebates are based on low income only – it excludes single person rebates)
3. A householder is vulnerable to living in a cold home as identified in the NICE guidance
4. A householder is referred and a Local Authority run scheme which aims to support low income in vulnerable households (LA Flex)
5. A householder receives free school meals
6. A householder identified as struggling with sustained debt or utility bills and mortgage payments and has been referred to the Local Authority for support by the Citizens Advice Bureau, their energy supplier or from their mortgage lender.

PART C

1. When was your home built?*

2. What type of home do you have?*

House
Bungalow
Flat
Maisonette

2b. Is your home:*

Detached
Semi-detached
End terrace
Mid-terrace

2b. Floor level:*

Top floor
Mid floor
Ground level
Basement

How many storeys does your home have?*

How many bedrooms in the property?*

How much of your home is double glazed?*

What type of roof does your home have?*

Are your external walls:*

If ‘other’ please specify.

PART D

1. What is your main heating system in your home?*

If ‘other’ please specify.

Make of heating system:

2. What fuel does your main heating system use?*

3. What controls does your heating system have?*

4. How do you heat your hot water in your home?*

If ‘other’ please specify.

PART E: Consent

Household Statement*

I can confirm the information I have provided is correct and to the best of my knowledge. I give permission for the information in this form to be used by Affordable Warmth Solutions CIC for the purpose of this project.

The information may be transferred, processed and used for reporting to Ofgem and Cadent Gas. This information will not be given to other companies or agencies without your permission and will be held in accordance with the General Data Protection Regulation (GDPR) 2018 and any successor legislation to the GDPR or the Data Protection Act 1998.

Affordable Warmth Solutions