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Name
*
First
Last
Email
*
Phone
*
Address
*
City
*
State / Province / Region
*
Postal Code
*
Country
*
What is your current tenure?
*
Homeowner
Privately Renting
Social Housing Rented
What is your EPC Rating? ( optional )
Unsure
A
B
C
D
E
F
G
Is there Gas connection to the property?
*
Yes
No
Was your gas meter installed before 31st March 2022?
*
Yes
No
Current main heating system
*
Gas central heating
LPG central heating
Electric heating
Oil central heating
Renewable heating
Infrared central heating
Secondary heating system
*
Electric panel or oil room heater
Solid fuel fires
Storage heaters
None
What is your boiler type?
*
Combi Boiler
Condenser Boiler
1960 to 1980 Back Boiler
The make and model of your boiler? ( optional )
Do you have a separate hot water cylinder?
*
Yes
No
Does your property have a loft or a room in the roof?
*
Yes
No
Is the loft insulated?
*
Yes
No
What is your property type?
*
Detached
Semi-Detached
Mid Terrace
Maisonette
Bungalow
Flat
What is the wall Type?
*
Solid brick wall
Cavity wall
Stone wall
Unsure / Other
Do you have any wall insulation?
*
Filled Cavity
External wall insulation
Internal wall insulation
No insulation / Unsure
Your Option of Heating available with the Funding
*
High Heat Electric Storage Heaters
First Time Central Heating
Air Source Heat Pumps
Solar PV
What is your current heating system?
*
Electric underfloor heating
Electric storage heaters
Gas central heating from boiler
Gas fire / back boiler
Solid fossil fuel fire / open fire
Bottled LPG Heating
Wood/biomass heating
Oil heaters
No heating in place
Select the Benefit You Are Receiving?
*
Child Tax Credits (CTC)
Child Benefits - depends on income threshold
Jobseekers Allowance (JSA)
Employment & Support Allowance (ESA)
Income Support (IS)
Pension Credit Guarantee Credit
Universal Credit (UC)
Warm Home Discount Scheme Rebate
Working Tax Credit (WTC)
Housing Benefit
Pension Credit Saving Credit
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