Title Page
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Title:
- Mr,
- Mrs,
- Miss,
- Ms,
- Dr,
- Rev,
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Inspection Date
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First Name:
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Surname:
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First Line of Address & Post Code,
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Full Address
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I, the above named, hereby confirm that I am the owner-occupier, or private tenant of the above property and that I, or a member of my household, meet the Qualifying Criteria below
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I confirm I have received a copy of the GDPR Privacy Notice for the ‘Home Upgrade Grant Phase 2’
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I can also confirm that I have provided proof of and qualify by either:
- Our household income is below £31,000 per year
- I receive an eligible income or disability benefit
- I live in a qualifying postcode (Lower Super Output Area 1-3)
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Which benefits are you in receipt of:
- Income based jobseekers Allowance (JSA)
- Income related Employment & Support Allowance (ESA)
- Income Support (IS)
- Pension Credit Guarantee Credit (PCGC)
- Working Tax Credit (WTC)
- Child Tax Credit (CTC)
- Universal Credit (UC)
- Housing Benefit (HB)
- Pension Credit Savings Credit (PCSC)
- Child Benefit (subject to income caps & composition)
- Attendance Allowance (AA)
- Disability Living Allowance (DLA)
- Armed Forces Independence Payment
- Carer's Allowance (CA)
- Industrial Injuries Disablement Benefit (IIDB)
- Personal Independence Payment (PIP)
- Severe Disablement Allowance (SDA)
- Mobility Supplement (MS)
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Please evidence address on Utility Bill
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Please capture evidence of household Income
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I, the client state that the information provided is true and accurate to the best of my knowledge and belief
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I, the client are aware that active fraud protection will be conducted during the operation of the scheme.
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Signed:
Assessor Declaration
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Assessor declaration: I confirm I have seen proof of the qualifying income and/or benefit criteria stated above
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LA Area: BCP/Dorset
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Assessor Signed For: Ridgewater Energy
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The fuel used for heating this property is either: Electric Oil LPG Solid fuel
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The EPC rating for the property is (Band/Score e.g., D68):
