Social Housing 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

2. Does your property have a registered EPC?*

Yes
No

If 'Yes' what is the EPC rating?

3. What is the name of your social housing group?

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:

5a. 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):

5b.What are your housing costs and do you receive any help to pay your housing bills?

Housing costs each year:

Rent:

Council Tax:

Housing help each year:

Housing Benefit:

Council Tax Reduction:

6a. How do you pay for your household energy?*

Quarterly
Direct Debit
Pre-payment

PART B

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 C

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 D: 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