Application for flexible eligibility declaration with Local Authority

APPLICANT DETAILS

Application For
---Nest ThermostatFirst Time Central Heating

Local Authority
---Havant BoroughEast HantsPortsmouthGosportWinchesterBournemouth And Poole

Name

Phone

E-mail

Address

Postcode

Number of Adults at Property?

Number of Children (Under 16) at Property?

Date of Birth

PROPERTY DETAILS

Tenure Type
---Owner OccupierPrivate TenantSocial Landlord

Property Type
---HouseFlatBungalowPark Home

Property Detachment
---Mid-TerraceEnd-TerraceSemi-DetachedDetached

Main Wall Type
---Solid-UninsulatedCavity Wall-UnfilledSolid-Insulated or Cavity-FilledUnknown

No. of Bedrooms
---12345+

Built Before 1964
---YesNoDon't Know

Fuel
---Mains GasLPGOilElectric

PROPERTY DETAILS

Do you know if the property has an EPC?
---YesNoDon't Know

If yes, what is the rating?
---ABCDEFGDon't Know

Is your Annual Household Income £35,000 or less after paying rent or mortgage, council tax, utility bills and buildings insurance?
---YesNo

Please confirm if you, or another household member, meet the relevant condition(s). Please tick all that apply:

People with cardiovascular conditions
Yes

Respiratory conditions (e.g. chronic obstructive pulmonary disease and childhood asthma)
Yes

People with mental health conditions
Yes

Dementia, learning disabilities, mental ill-health that reduces individual’s ability to self-care
Yes

Older people (60 and older)
Yes

Households with young children (Aged Newborn to 5)
Yes

Households with older children (Aged 6-15)
Yes

Pregnant women
Yes

People who are terminally ill
Yes

People with suppressed immune systems (e.g. from cancer treatment or HIV, etc)
Yes

People who move in and out of homelessness
Yes

People with addictions
Yes

People who have attended hospital due to a fall
Yes

Recent immigrants, asylum seekers and refugees (if living in private tenure)
Yes

Households in debt
Yes

DECLARATION

I, as the householder, confirm that details entered are true and accurate.

Name

PRIVACY NOTICE: Personal information you provide is held securely and will be used only for the purpose of assessing ECO Flexible Eligibility and related local authority purposes.
By completing this form, you agree to consent to your information being shared with the relevant Obligated Energy Supplier for the purposes of obtaining ECO Flexible Eligibility funding for the installation of retrofit measures on your home. The local authority may legally share this information with other organisations if it is necessary to protect public funds and/or to prevent fraud.
Your personal information will only be retained and used for as long as is necessary in line with data protection law. Your information will be destroyed or deleted in line with relevant destruction policies and processes.