Title
Mrs
Mr
Miss
Ms
First Name
Surname
National Insurance Number
Agent Id
Agent Id
Postcode
btn_PostcodeSearch
Line 1
Line 2
Town
Telephone number
Email_Address
Q 1 - 1
Yes
Q 1 - 0
No
Q 2 - 1
Yes
Q 2 - 0
No
Q 3 - 1
Yes
Q 3 - 0
No
Q 4 - 1
Yes
Q 4 - 0
No
Q 5 - 1
Yes
Q 5 - 0
No
Q 6 - 1
Yes
Q 6 - 0
No
Q 7 - 1
Yes
Q 7 - 0
No
Q 8 - 1
Yes
Q 8 - 0
No
Q 9 - 1
Yes
Q 9 - 0
No
Q 10 - 1
Yes
Q 10 - 0
No
Q 11 - 1
Yes
Q 11 - 0
No
Q 12 - 1
Yes
Q 12 - 0
No
Q 13 - 1
Yes
Q 13 - 0
No
Q 14 - 1
Yes
Q 14 - 0
No
Q 15 - 1
Yes
Q 15 - 0
No
Q 16 - 1
Yes
Q 16 - 0
No
Q 17 - 1
Yes
Q 17 - 0
No
How often do you feel cold in your home?* - 1
All the time
How often do you feel cold in your home?* - 2
Sometimes
How often do you feel cold in your home?* - 3
Never
Do you struggle to pay energy bills?* - 1
All the time
Do you struggle to pay energy bills?* - 2
Sometimes
Do you struggle to pay energy bills?* - 3
Never
Do you have damp or mould in your home?* - 1
All the time
Do you have damp or mould in your home?* - 2
Sometimes
Do you have damp or mould in your home?* - 3
Never
How old is your park home property?* - 1
0-10 yrs
How old is your park home property?* - 2
11-20 yrs
How old is your park home property?* - 3
21-30 yrs
How old is your park home property?* - 4
How old is your park home property?* - 5
How long have you lived in a park home?* - 1
0-5 yrs
How long have you lived in a park home?* - 2
6-10 yrs
How long have you lived in a park home?* - 3
11-15 yrs
How long have you lived in a park home?* - 4
16-20 yrs
How long have you lived in a park home?* - 5
Do you own or rent your park home?* - 1
Own
Do you own or rent your park home?* - 2
Rent
Are you a member of any park home or park residents associations?* - 1
Yes
Are you a member of any park home or park residents associations?* - 2
No
Do you have access to the internet?* - 1
Yes
Do you have access to the internet?* - 2
No
How do you heat your water?* - 1
How do you heat your water?* - 2
How do you heat your water?* - 3
Other. Please specify
How do you heat your water - please specify
Are you billed for your electricity by your park site owner?* - 1
Yes
Are you billed for your electricity by your park site owner?* - 2
No
Is your electric bill calculacted from a sub-meter - 1
Yes
Is your electric bill calculacted from a sub-meter - 2
No
Do you have Liquid Petroleum Gas (LPG)?* - 1
Yes
Do you have Liquid Petroleum Gas (LPG)?* - 2
No
Do you have mains gas supply?* - 1
Yes
Do you have mains gas supply?* - 2
No
Have you been referred to this scheme by the Department of Work & Pensions (DWP)? - 1
Yes
Have you been referred to this scheme by the Department of Work & Pensions (DWP)? - 2
No
Please confirm if you have received and read the Park Homes Warm Home Discount leaflet?* - 1
Yes
Please confirm if you have received and read the Park Homes Warm Home Discount leaflet?* - 2
No
Declaration - 1
Declaration_Accepted_Date
Submit Form
Charis Grants - Park Homes Warm Home Discount Scheme
1st April 2015 to 31st March 2016
Email address
Telephone number
Your details:
Postcode
Town
Line 2
Line 1
Address
You can read about the scheme and eligibility criteria at
https://www.parkhomeswhd.com
Surname
First name
Title
Name
National Insurance Number
For data collection could you please answer the following questions:
How often do you feel cold in your home?*
Do you struggle to pay energy bills?*
How old is your park home property?*
Do you have damp or mould in your home?*
More than 31 yrs
Don't know
How long have you lived in a park home?*
More than 21 yrs
Do you own or rent your park home?*
Are you a member of any park home or park residents associations?*
Do you have access to the internet?*
How do you heat your water?*
Are you billed for your electricity by your park site owner?*
Do you have Liquid Petroleum Gas (LPG)?*
If yes, is your electric bill calculated from a sub-meter for your own park home?
Do you have mains gas supply?*
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 (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?
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 (or partner) in receipt of a Disabled Child Premium as part of your benefit?
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 you (or partner) in receipt of a Disability Premium as part of your benefit?
Are you in receipt of Child Tax Credits that includes a Disability or Severe Disability element?
Are your fuel bills for heating more than 10% of your gross annual household income?
Have you been referred to this scheme by the Department of Work & Pensions (DWP)?*
Combi Boiler
Immersion Heater
Please confirm if you have received and read the Park Homes Warm Home Discount leaflet?*
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 can write to Charis Grants at the address below at any time to withdraw your consent.
You will not be registered for this scheme unless you accept and date this consent statement
Consent Statement
Charis Grants Limited
Registered in England & Wales: No 04762902. Midgate House, Midgate, Peterborough PE1 1TN
charisgrants.com
If you have any difficulty completing this form please contact Charis Grants on 0330 380 1040.
Date