In order to register your interest in the Warm Home Discount Scheme, please answer either 'Yes' or 'No' to all questions below by selecting the applicable boxes:
Are you (Or Partner) in receipt of Pension Credit with Guarantee & Savings or Pension Credit with Savings only?
Are you (Or Partner) in receipt of a State Pension?
Do you (Or Partner) receive Income Related Employment and Support Allowance (ESA) that includes a work related activity or support component?


Yes

No
British Gas Warm Home Discount Scheme
1st August 2016 to 31st May 2017
picture
Do you (Or Partner) receive Income Based Jobseekers Allowance (JSA) or Income Support?
Are you (Or Partner) in receipt of Universal Credit and are either not in work or are self-employed?
Are you (Or Partner) in receipt of a limited capability for work element with or without a work-related activity element as part of your Universal Credit?
Do you have parental responsibility for a child aged 5 or under?
Are you in receipt of Child Tax Credits that includes a Disability or Severe Disability element or Universal Credit equivalent?
Email Address

Tel No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No
Your Details:






Postcode
Town
Line 2
Line 1
Address
Name
Title
First Name
Surname

You can read about the scheme and eligibility criteria at http://www.britishgas.co.uk/whd
Electricity Account Number

Is your electricity supplied by British Gas or Sainsbury's Energy?

Yes

No

Agent Id
British Gas Trading Limited
Registered in England & Wales: No 3078711. Millstream, Maidenhead Road, Windsor, Berkshire, SL4 5GD.
britishgas.co.uk
If you have any difficulty completing this form please contact British Gas on 0800 072 8625. Prepayment customers please call 0800 294 8604


Consent Statement
You will not be registered for this scheme unless you accept and date this consent statement
I understand that you may need to check that I am eligible for the Warm Home Discount Scheme. 
I agree to British Gas asking the Department for Work and Pensions to confirm whether I am in receipt of a qualifying benefit.
This information will be used for the purposes stated above and to check if you are entitled to any other benefits or discounts which might reduce your energy consumption and to help detect and prevent debt. We may share your information with other third parties, including but not limited to the DWP for these purposes.
You can write to British Gas at the address below at any time to withdraw your consent.
I understand that:
• If the Department for Work and Pensions cannot confirm that I receive the qualifying benefits to be eligible to receive the discount I may need to send British Gas copies of my benefit letters.
• If I change supplier before my discount is paid I will no longer be eligible.

Are you (Or Partner) in receipt of a Disabled Child Premium or Universal Credit equivalent as part of your benefit?

Yes

No
Are you (Or Partner) in receipt of a Disability Premium or Universal Credit equivalent as part of your benefit?

Yes

No
Are you (Or Partner) in receipt of a Pensioner Premium as part of your benefit?
Is your Gross Annual Household Income (Before tax and deductions) less than £16,190?
Does anyone in your household require constant care?
Does anyone in your household rely on mains powered medical equipment?
Is anyone in your household in receipt of Disability benefits or registered disabled?
Does anyone in your household suffer from a long term physical or mental illness?
Are your fuel bills for heating more than 10% of your Gross Annual Household Income?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Date