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Fuel Voucher Application Form

Energy Redress Scheme

Please fill out the form below

I have confirmed that the client is in fuel crisis, and I am satisfied that their ID matches the details given in this application*(Required)
Please confirm with the client that they are using a pre-payment meter*(Required)
Does the client top-up their pre-payment meter at a Post Office?*(Required)
Has the client had more than 1 voucher in any 10 day period?*(Required)
Has the client had more than 3 vouchers in a 6 month period?*(Required)
Has energy advice been provided by your organisation?
How the client wishes to receive their code?*(Required)
Is this the client's mobile number?*(Required)

Address(Required)

Are there any adults of pensionable age in the household?
Does the client have a Smart Meter for their gas supply?*(Required)
Does the client have a Smart Meter for their electricity supply?*(Required)

Customer Declarations

This form MUST be completed by an authorised person and MUST NOT be submitted until the points below are confirmed with the client and ticked where appropriate. Failure by the client to provide confirmation in relation to certain points will mean the application cannot proceed.

Questions 1 – 3 are mandatory in order to process the fuel voucher application.
1. By submitting this form, you confirm the following:*
Consent(Required)
2. By submitting this form, you confirm the following:*
Consent(Required)
3. By submitting this form, you confirm the following:*
Consent(Required)
4. By submitting this form, you confirm the following:
Consent
5. By submitting this form, you confirm the following:
Consent
6. By submitting this form, you confirm the following:
Consent