British Gas Warm Home Discount Scheme
1st April 2015 to 31st March 2016
You can read about the scheme and eligibility criteria at
Address Line 1
Address Line 2
Is your electricity supplied by British Gas or Sainsbury's Energy?
Have Electricity With British Gas - 1
Have Electricity With British Gas - 0
Electricity Account Number
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?
Q1 - 1
Q1 - 0
Q2 - 1
Q2 - 0
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?
Q3 - 1
Q3 - 0
Q4 - 1
Q4 - 0
Do you (Or Partner) receive Income Based Jobseekers Allowance (JSA) or Income Support?
Q5 - 1
Q5 - 0
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?
Q6 - 1
Q6 - 0
Q7 - 1
Q7 - 0
Do you have parental responsibility for a child aged 5 or under?
Q8 - 1
Q8 - 0
Are you in receipt of Child Tax Credits that includes a Disability or Severe Disability element?
Q9 - 1
Q9 - 0
Are you (Or Partner) in receipt of a Disabled Child Premium as part of your benefit?
Q10 - 1
Q10 - 0
Are you (Or Partner) in receipt of a Disability Premium as part of your benefit?
Q11 - 1
Q11 - 0
Are you (Or Partner) in receipt of a Pensioner Premium as part of your benefit?
Q12 - 1
Q12 - 0
Is your Gross Annual Household Income (Before tax and deductions) less than £16,190?
Q13 - 1
Q13 - 0
Does anyone in your household require constant care?
Q14 - 1
Q14 - 0
Does anyone in your household rely on mains powered medical equipment?
Q15 - 1
Q15 - 0
Does anyone in your household suffer from a long term physical or mental illness?
Q16 - 1
Q16 - 0
Is anyone in your household in receipt of Disability benefits or registered disabled?
Q17 - 1
Q17 - 0
Are your fuel bills for heating more than 10% of your Gross Annual Household Income?
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
Consent Box - 1
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.
British Gas Trading Limited
Registered in England & Wales: No 3078711. Millstream, Maidenhead Road, Windsor, Berkshire, SL4 5GD.
If you have any difficulty completing this form please contact British Gas on 0800 072 8625. Prepayment customers please call 0800 294 8604