Eform | FCC

Address for the Gas Supply

Find address

Phone number of the Gas Supply Address

Do you live at the gas supply address?

Yes No

You must live at the house to claim a grant

Are you currently Building your house?

Yes No

Are you currently Renovating your house?

Yes No

Are you the property owner?

Yes No

Please provide evidence of ownership

Attachments

Are you an occupier of the property? (you live in home but do not own or rent it)

Yes No

Please provide evidence of residency

Attachments

A private tenant?

Yes No

Please provide evidence of tenancy

Attachments

Please provide Landlord's name

Please provide Landlord's address

Find address

Please provide Landlord's telephone number

How many Male adults live in your household and what are their ages?

How many Female adults live in your household and what are their ages?

How many Children live in your household and what are their ages?

Is anyone usually at home during the day?

Yes No

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 other any other money received – after tax and any National Insurance payments.) Income – after tax: Week, or month or year

Each week £

Each Month £

Each year £

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

Mortgage per year £

Rent per year £

Council Tax per year £

Housing help each year

Mortgage Support £

Housing Benefit £

Council Tax Reduction £

Please explain if your surname differs from the name on your evidence

Please explain if your address differs from the address on your evidence

How do you pay for your household energy?

Quarterly Direct Debit Pre-payment

How much do you pay for your household energy in a year?

Please select your existing fuel

Unit cost day £

Unit cost night £

Standing charge each year (if applicable)

Cost per KWH, Litre or Tonne

Statement of Benefits

Where do you live?

England Wales

Please upload copies of your benefit award letters

Attachments

What type of home do you have?

House Bungalow Flat Maisonette

Is your home

Detached Semi-detached End terrace Mid-terrace

Floor level

Top floor Mid floor Ground level Basement

How many storeys does your home have

How many bedrooms in the property

How many living/dining rooms in the property

How much of your home is double glazed?

None Some (up to 25%) Half (50%) Most (75%) All (100%)

Are your window frames made of?

Wood Plastic/UPVC Metal

What type of roof does your home have?

Flat Pitched - No Access Pitched roof Pitched (Thatch) Pitched / Loft Access Another Dwelling Above

Are your external walls?

Solid brick Cavity Timber frame Concrete Stone Other

Please specify

What wall insulation do you have?

No insulation Filled Cavity Insulation Internal Wall Insulation Unknown As Built External Insulation

What is your main heating system in your home?

Standard Boiler Warm Air System Condensing Boiler Storage Heaters Combi Boiler Room Heaters / Fires Condensing - Combi Boiler Other

Please specify

What fuel does your main heating system use?

What controls does your heating system have?

No controls Heater/Fire thermostat Programmer and Room thermostat Radiator valve thermostat Manual Charge Control Automatic Charge Control

What is the make of your boiler?

...and model

...and is your boiler?

Wall mounted Floor standing Back boiler

How do you heat your hotwater in your home?

From main heating system (boiler) From secondary heating Back boiler Electric Immersion (off-peak) Instant Electric water heating Electric Immersion (on-peak)

Cylinder size?

No Cylinder Normal 90 - 130 litres (up to 90cm / 36' tall) Medium 131 - 170 litres (between 90cm / 36' to 135' / 54' tall) Large > 170 litres (over 54' tall) No Access

What is your cylinder insulation type?

No insulation Factory fitted insulation (Solid Foam) Hot Water Tank Jacket

What thickness is your cylinder insulation?

None 12mm 25mm (Factory fitted - yellow) 35mm 38mm 50mm (Factory fitted - Green) 80mm 120mm 160mm

Does your cylinder have a Thermostat?

Yes No

Do you have any renewable technology in your home?

Yes No

Do you have any renewable technology in your home?

Solar PV Solar Thermal Air Source Heat Pump Other

Please specify the type of renewable energy technology

IF YOU ALREADY HAVE A QUOTATION FROM WALES & WEST UTILITIES LTD PLEASE ENTER THE DETAILS

CRM Ref

Quote Value excluding VAT

Quote Value including VAT

Date Quotation issued

Date Quotation valid until

By submitting this form I give permission for Flintshire County Council and its partners to use the information on this form for the purpose of this project

Gas Connection Grant Application

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Address

Gas Connection Grant Application

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