In order to register your interest in the Park Homes Warm Home Discount Scheme, please answer either 'Yes' or 'No' to all questions below by selecting the applicable boxes*:
Are you a permanent resident of a UK Park Home?

Yes

No
Charis Grants - Park Homes Warm Home Discount Scheme
1st August 2016 - 31st May 2017
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Mandatory Fields*
Your details:

Agent Id*
Email address

Name
Title*

First name*

Surname*


National Insurance Number*
Telephone* number

Address
Postcode*



Line 1*

Line 2*
Town*

You can read about the scheme and eligibility criteria at https://www.parkhomeswhd.com

Yes

No
Do you (or partner) pay Council Tax for your UK Park Home?

Yes

No
Are you (or partner) exempt from paying Council Tax for your UK Park Home?
Are you (or partner) in receipt of Pension Credit with Guarantee & Savings or Pension Credit with Savings only?

Yes

No
Are you (or partner) in receipt of a State Pension?

Yes

No
Do you (or partner) receive Income Related Employment and Support Allowance (ESA) that includes a work related activity or support component?


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?

Yes

No
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?

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 or Universal Credit equivalent?

Yes

No
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?

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?

Yes

No
Are you billed for your electricity by your park site owner?

Yes

No
Charis Grants - Park Homes Warm Home Discount Scheme
1st August 2016 - 31st May 2017
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Further information about your application:
How did you hear about the scheme?










Department for Work and Pensions (DWP)
Friend, family or neighbour
National Association of Park Home Residents (NAPHR)
Independent Park Home Advisory Service (IPHAS)
Local Authority
Citizens Advice Bureau (CAB)
Charis Grants website
Do you have any standalone kitchen appliances that are over 10 years old (tick as appropriate)?
Washing Machine - Other size
Freezer - Other size
Fridge - Other size




Washing Machine - 60cm
Freezer - 60cm
Fridge - 60cm




Washing Machine - 50cm
Freezer - 50cm
Fridge - 50cm
Please confirm if you have received and read the Park Homes Warm Home Discount mailshot?*

Yes

No




By post
Other
If you have any difficulty completing this form please contact Charis Grants on 0330 380 1040.
Charis Grants Limited
Registered in England & Wales: No 04762902.
3rd Floor, Trinity Court, Trinity Street, Peterborough, PE1 1DA
charisgrants.com
Energy Saving Advice*
Quick tips to see if you're saving as much energy as you could be;

• Use a washing up bowl to wash up rather than a running tap and save £30 a year in energy bills.
• Cutback your washing machine use by just one cycle per week and save £5 a year on energy and a further £8
a year on metered water bills
• Spending one minute less in the shower each day will save around £10 off your energy bills each year, per
person.  With a water meter this could save a further £10 off annual water and sewerage bills.
• Only fill the kettle with the amount of water that you need and save around £7 a year on energy bills.
Have you found the energy saving advice useful?*

Yes

No


I authorise Charis Grants Ltd to process my application in accordance with the Data Protection Act and consent for them to contact me directly about my application. I declare that the information I have given on this form is complete and correct to the best of my knowledge.

If I have obtained personal information about any other person (e.g. my partner) in support of this application, I confirm that I have obtained consent from that person to the use and sharing of that information.

I understand that you may need to check that I am eligible for the Warm Home Discount Scheme and may be selected for audit and be required to evidence my application.
You will not be registered for this scheme unless you accept and date this consent statement
Consent Statement*

Date
1 2