Your Details:

Title
Address
Name

Forename

Surname






Account Number
Email Address
Postcode
County
Town
Line 2
Line 1
found in the top right of your bill

Telephone Number
Confirm Email Address
Warm Home Discount Scheme
23rd July 2016 to 31st May 2017

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In order to register for the Warm Home Discount Scheme, please answer either 'Yes' or 'No' to all questions below.
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Part 1: Criteria
Do you (or household member) receive Income Based Jobseekers Allowance (JSA)?
Do you (or household member) receive Income Related Employment and Support Allowance (ESA)?
Do you (or household member) receive Income Support?

Yes

No

Yes

No

Yes

No
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Part 2: Qualifying Components

Yes

No

Yes

No

Yes

No
Do you (or household member) have parental responsibility for a child aged 5 or under?
Do you (or household member) receive Child Tax Credits or Universal Credit equivalent?
Do you (or household member) receive a Disabled Child Premium or Universal Credit equivalent as part of your benefit?
Is the Gross Annual Household Income (Before tax and deductions) less than £16,190?

Yes

No
Do you (or household member) receive Universal Credit?

Yes

No
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Declaration and Consent
I confirm that the information is up to date and factually correct and I agree to npower asking the Department for Work and Pensions or other third party organisations to confirm whether I am in receipt of a qualifying benefit. I understand that if they cannot confirm I receive the qualifying benefits I may need to send copies of my benefit letters. This information will only be used for the purposes stated above. I can write to npower at the address below at any time to withdraw consent, but I understand that this would mean my application is withdrawn.


Date

Do you (or household member) receive Disability Living Allowance (DLA) or Attendance Allowance (AA) or Personal Independence Payment (PIP)?
Do you (or household member) receive Long Term Incapacity Benefit?

Yes

No

Yes

No

Yes

No
Do you (or household member) receive a Disability, Enhanced Disability or Severe Disability Premium as part of your benefit or Universal Credit equivalent?
Do you (or household member) receive a Pensioner Premium, Higher Pensioner Premium or Enhanced Pensioner Premium?

Yes

No
Freepost NPOWER WARM HOME DISCOUNT
Phone  0808 172 6999 or 0330 100 8669
www.npower.com/spreadingwarmth
npower is a registered trademark and the trading name of
Npower Limited (Registered No. 3653277) Npower Gas Limited (Registered No. 2999919)
Npower Northern Limited (Registered No. 3432100) who also act as an agent for
Npower Northern Supply Limited (Registered No. 2845740) for the supply of electricity
Npower Yorkshire Limited (Registered No. 3937808) who also act as an agent for
Npower Yorkshire Supply Limited (Registered No. 4212116) for the supply of electricity
Registered in England and Wales
Registered Office: Windmill Hill Business Park, Whitehill Way, Swindon SN5 6PB




Do you (or household member) receive a limited capability for work element with or without a work-related activity element as part of your Universal Credit?

Yes

No