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British Gas Warm Home Discount Scheme
1st April 2015 to 31st March 2016
You can read about the scheme and eligibility criteria at http://www.britishgas.co.uk/whd
Your Details:

Agent Id
Name

Title
Address

First Name
Postcode

Surname
Line 1

Is your electricity supplied by British Gas?
Line 2

Yes
No

Town

Electricity Account Number

Tel No

Email Address
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?
Yes
No

Yes
No

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

Yes
No

Do you (Or Partner) receive Income Based Jobseekers Allowance (JSA) or Income Support?
Yes
No

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?
Yes
No

Yes
No

Do you have parental responsibility for a child aged 5 or under?
Yes
No

Are you in receipt of Child Tax Credits that includes a Disability or Severe Disability element?
Yes
No

Are you (Or Partner) in receipt of a Disabled Child Premium as part of your benefit?
Yes
No

Are you (Or Partner) in receipt of a Disability Premium as part of your benefit?
Yes
No

Are you (Or Partner) in receipt of a Pensioner Premium as part of your benefit?
Yes
No

Is your Gross Annual Household Income (Before tax and deductions) less than £16,190?
Yes
No

Does anyone in your household require constant care?
Yes
No

Does anyone in your household rely on mains powered medical equipment?
Yes
No

Does anyone in your household suffer from a long term physical or mental illness?
Yes
No

Is anyone in your household in receipt of Disability benefits or registered disabled?
Yes
No

Are your fuel bills for heating more than 10% of your Gross Annual Household Income?
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 only be used for the purposes stated above.
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.

Date
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