Title Page
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Site conducted
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PNG Application Number
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Applicant First Name
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Applicant Surname
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Contact Telephone Number 1
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Mobile Telephone Number 2
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E-mail Address
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Co-Applicant First Name
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Co-Applicant Surname
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Contact Tel
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Address Line 1
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Address Line 2
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Town
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Postcode
Applicant Survey
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Applicant Income Eligibility - applicable criteria met
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Existing Boiler Eligibility
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Property Type
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Number of Bedrooms
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Tenure of Property
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If Homeowner - is this property your main place of residence?
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If Homeowner - do you currently reside in the property and are not currently seeking to sell the property?
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Year Property was built
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Is your property located in a conservation area?
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Current Heating System
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Proposed New Heating System
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Is existing boiler broken beyond viable economic repair?
- Yes
- No
- N/A
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Is existing boiler > 15 years old?
- Yes
- No
- N/A
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Existing Boiler Manufacturer
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Existing Boiler Model
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Existing Boiler Year of Manufacture
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Is your property located more than 50 metres from a gas distribution pipeline?
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Has customer been assessed under the Affordable Warmth Scheme?
- Yes
- No
- N/A
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Has customer been accepted under the Affordable Warmth Scheme? If Yes - NISEP grant cannot be offered
- Yes
- No
- N/A
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Have you been accepted under any other government funded programme or availed of a grant in previous years, for a similar measure? This includes any previous NISEP Scheme or Boiler Replacement Allowance.
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If "Yes" - please name the Scheme and installer
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What is the Gross Annual Income of the Applicant Household?
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What is the Gross Monthly Income of the Applicant Household?
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Has evidence been provided to verify applicant household income?
- Yes
- No
- N/A
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What evidence has been provided by applicant and verified by surveyor?
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If "Other" - please specify
Data Protection Statement, Consent for System Monitoring and Customer Declaration
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Data Protection - We will store your data securely, treat your data with respect and in compliance with current General Data Protection Regulation (GDPR) requirements. Your data will be passed on to the programme Administrator in order to process payment of grant funding, if your application to the scheme is successful. We will not share your data with any other third party without your written consent. Your personal data will be shared with your local Building Control Office (to apply for Building Control for the works), your heat pump manufacturer (to register your equipment warranty), Met Collect (for safe removal of your old Oil Tank), Energystore (for Cavity Wall Insulation install), H&A Mechanical (for Post Installation Audit / Quality Monitoring Inspection), MCS (for certification of your heat pump) and IWA (for workmanship insurance backed guarantee for your new heating system).
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System Monitoring - All Heat Pumps installed under this scheme will be installed with an external monitoring system configured by Carnego Systems, to allow the monitoring of the performance of the conversion for a maximum of 2 years. The monitoring system will consist of a hub and various sensors located at different points on the heating system. These sensors will communicate with the hub. The sensors will monitor internal and external temperatures and automated heat and electricity readings relating to the heat pump. It will communicate with the monitoring portal through a 4G internet connection provided by Carnego - this cannot be used by the customer. Data from the monitoring system will be shared with the Energy Saving Trust, the Utility Regulator and the Department of the Economy for the purpose of informing future policy on heat pumps. Data from the monitoring system will also be shared with installer and Primary Bidder for the purpose of monitoring system performance and fault diagnosis and detection. Customer Consent - By signing this declaration I confirm that I am content for the external monitoring system to be installed for the purposes of monitoring the performance of the heat pump system and I confirm that I am content for the data from the monitoring system to be shared with the stakeholders listed above.
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Customer Declaration – I declare that to the best of my knowledge the details provided on this form are correct. – I understand that if I give information that is incorrect or incomplete, I will be liable to prosecution. – I/we declare that I/we have accurately recorded all sources of income received. – I/we understand that we may be liable to prosecution if we make false statements. – I/we understand that Phoenix Natural Gas / Refresh Property Solutions Ltd may share my details with other agencies as appropriate for the purposes of completing this grant application and the associated works. – I/we understand that Phoenix Natural Gas / Refresh Property Solutions Ltd will contact us and/or other agencies as appropriate to verify the information provided. - I can confirm that I am fully aware that because the unit cost of all fuel prices can fluctuate over time , no guarantees can be given over future running costs. My decision to avail of NISEP is based on the lifetime benefit of the heat pump (estimated 12-15 years) and not on the short term running costs.
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I have read, understood and agreed the above Customer Declaration and want to submit an application to the Phoenix Efficiency Plus 2023/24 NISEP Scheme
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Signature of Joint Applicant - I have read, understood and agreed the above Customer Declaration and want to submit an application to the Phoenix Efficiency Plus 2023/24 NISEP Scheme
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Refresh Property Solutions Surveyor Declaration: • I declare that to the best of my knowledge the details provided on this form are correct and where noted above that information has been verified to source documentation, I declare that I have seen said source documentation.
