Energy Efficiency Enquiry Form

This form will help identify what your energy efficiency needs might be, and if there is any help that the Council can provide. It should be completed by the occupier of the property.
Your details
1. Title:*
2. First name:*
3. Surname:*
4. Your address
  1. Postcode*
    
    Address
7. Email address:*
8. Phone number:*
Are you the Occupier?
1. Yes
  
  No
Are you the owner or a tenant?
1. I am the owner
  
  I am a tenant
If you are a tenant, please tell us the landlord or the owner's details.
1. Landlord's/Owner's details
  1. Title:
  2. First name:
  3. Surname:
  4. Email address:
  5. Phone number:
2. Landlord's/owner's address
  1. Postcode
    
    Address
Section 1 - Income Threshold and Vulnerability to the cold
Are you, or any member of the housing, receiving any of the following benefits? Please tick all that apply.
1. Income Related Employment and Support Allowance (ESA)
2. Income Based Job Seekers Allowance (JSA)
3. Personal Independence Payment (PIP)
4. Child Tax Credit
5. Working tax Credit
6. Universal Credit
7. Pension Guarantee Credit
8. Income Support
9. Disability Living Allowance
10. Attendance Allowance
11. Carer's Allowance
12. Severe Disablement Allowance
13. Industrial Injuries Disablement Benefits
14. War Pensions Mobility Supplement
15. Constant Attendance Allowance
16. Armed Forces Independence Payment
17. Child Benefit
Is the Household income (after housing costs) less than £35,000 per annuum?
1. Yes
2. No
Do any of the following apply to you or a member of your household? Please tick all that apply.
1. Aged over 60
2. Aged over 75
3. Has children under 16
4. Pregnant
5. Respiratory Disease (e.g. COPD, asthma
6. Cardiovascular Disease (e.g ischaemic heart disease, cerebrovascular disease)
7. Moderate to severe mental illness (e.g. schizophrenia, bipolar disorder)
8. Substance misusers
9. Dementia
10. Neurobiological and related diseases (e.g. fibromyalgia, ME)
11. Cancer
12. Limited mobility
13. Haemoglobinopathies (e.g. sickle cell disease, thalassaemia)
14. Severe learning disabilities
15. Autoimmune and immunodeficiency disease (e.g. lupus, MS, diabetes, HIV)
Section 2 - Property Efficiency
Is the EPC rating of the property D or below?
1. Yes
2. No
3. My property doesn't have an EPC
4. Don't know
How do you currently heat your property?
1. Solid Fuel (e.g. woodburner, coal fire)
2. Electric Heating
3. No central heating
4. Other
If you selected other, please provide details below.
1. Other
What improvements are you looking for?
1. Improve heating efficiency
2. Improve Insulation
3. Both
Declaration of Eligibility
I declare that I meet the income/vulnerability criteria in section 1 and the property efficiency criteria in section 2.
The Council will use your information to assess your energy needs, and depending on what help or funding is available, we may pass your details to an installer. The installer will organise a technical survey and installation, should you decide to proceed.

For more information about how we handle your data, please see https://www.southhams.gov.uk/Privacy or https://www.westdevon.gov.uk/Privacy
By clicking submit, you consent to us using your personal data as described above.
I have read the declaration and consent to my personal data as detailed in this form being used as described above.
1. Tick here to confirm

Energy Efficiency Enquiry Form

This form will help identify what your energy efficiency needs might be, and if there is any help that the Council can provide. It should be completed by the occupier of the property.

Section 1 - Income Threshold and Vulnerability to the cold

Section 2 - Property Efficiency

Declaration of Eligibility

I declare that I meet the income/vulnerability criteria in section 1 and the property efficiency criteria in section 2.