Gas Cap Request Form

• Name

• Address

• Conducted on

  Date

• Prepared by

Customer request & declaration for capping gas supply

• * I request that CCHA caps my gas supply to my home. I understand that this means that my gas central heating and hot water system, and my gas cooker will not work for as long as the cap is in place.

  Yes

  No

  N/A

• * I understand that CCHA will not be responsible for supplying alternative electric powered heating or shower or cooking facilities not already provided.

  Yes

  No

  N/A

• * I understand that I am making this request at my own risk and that the lack of heating and hot water could affect my health and wellbeing.

  Yes

  No

  N/A

• * I understand that I may request at any time for CCHA to reconnect my gas supply and that this will be completed within 24 hours of my request provided I have a gas supply to my property.

  Yes

  No

  N/A

By making this request, I agree to the following actions to ensure the risk to me, my household and the property is minimised:

• * To engage with the Money Solutions team to take action to deal with any financial barriers to getting my supply back on if affordability of gas is an issue for me;

• * The housing team to attend and inspect at the 6 monthly cap check to check the condition of my home (e.g. for damp and mould);

• *To use alternative heating within my home where needed;

• * To let CCHA know if I have any health issues or changes to my circumstances that may be adversely affected by supply being capped, eg, new baby or chronic health issue

• * To report any repairs to CCHA and allow access for them to be undertaken;

undefined

• Signed

  Sign

• Date

  Date