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WARM HOME DISCOUNT APPLICATION 2013-2014
PLEASE COMPLETE FORM CLEARLY IN CAPITAL LETTERS USING A PEN WITH BLACK INK

Electricity Account Number
Electricity Account Holders Details
Title (Mr, Mrs etc)

First name

Last name

Address

Postcode
Name of the person who receives qualifying benefit (known on this form as ‘Claimant’ or ‘Benefit Claimant’)
Please note that only the named electricity account holder or their partner/spouse may apply for a Warm Home Discount rebate

Claimant’s Title
(Mr, Mrs etc)

First name

Last name
Day

Month

Year

Claimant’s Date of Birth
Please indicate below the Benefit Claimant’s relationship to the account holder
I am the Account Holder

Partner/Spouse

Other (specify)

Please give contact details for either the Benefit Claimant or the Account Holder
Telephone

Mobile

Email

Section A
Main Benefit (you need to be in receipt of at least one Main Benefit)
Please place a tick () in each box to indicate that you receive this type of benefit
Income-based Jobseeker’s Allowance

Income-based Employment and
Support Allowance

Income Support
Additional Benefits (you will also need to be in receipt of at least one of these)
Disability Living Allowance

Severe Disablement Allowance

Incapacity Benefit

Industrial Injuries Benefit

War Disablement Pension

Additional payment because I am
Sick or disabled

There are children living with me who
were born after 01 April 2008

Child Disability Allowance/Child Tax
Credit which includes a disability
premium for a child living with me
who was born on or after 01 April 1994

If you have ticked to confirm that you meet the criteria in Section A, please continue to the
DECLARATION on the back of this form.