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Personal Details
Title
Mr
Mrs
Miss
Ms
Prefer not to say
First Name
*
Last Name
*
Email Address
*
*
*
Contact Number
*
*
Alternative Contact Number
*
Date of Birth
*
*
Address
*
*
Town
*
*
Post Code
*
*
Country
*
England
Scotland
Wales
Northern Ireland
The Energy Efficiency Schemes predominantly require Insulation, then Heating before any Solar eligibility. Please confirm that you will accept insulation and heating measures identified as required to progress through the scheme. These will be discussed with you
Customer Acceptance
No
Yes
Property Details
Property Type
*
Flat
Maisonette
Detached House
Semi-detached House
Mid Terraced House
End Terraced House
Park Home
Detached Bungalow
Semi-detached Bungalow
Mid Terraced Bungalow
End Terraced Bungalow
Total Floor Area (Sq m)
*
*
Please enter a value greater than 0
Ownership
*
Owner Occupier
Private Rented
Social Housing
Landlord Name
*
Adult Occupants (>18)
0
1
2
3
4
More
Child Occupant (<18)
0
1
2
3
4
5
6
More
Occupants over 65
0
1
2
3
4
More
Current EPC Rating
*
Current Heating System
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Existing Measures Installed
Application Source
LA/Local Authority
Brokerage
Lead Gen
Customer
Lead Gen - CES
Eligibility
Are you in receipt of Government Benefits?
*
No
Yes
Benefit Name
If you answered yes to the above, please identify the Benefit you are in receipt of from the below list. Note that if you are in receipt of more than one of the qualifying benefits, you only need to select one.
Housing Benefit (new eligible benefit under ECO4)
Pension Credit Savings Credit (new eligible benefit under ECO4)
Child Benefit Income Single Claimant 1 £19,900
Child Benefit Income Single Claimant 2 £24,800
Child Benefit Income Single Claimant 3 £29,600
Child Benefit Income Single Claimant 4+ £34,500
Child Benefit Income Couple Claimant 1 £27,500
Child Benefit Income Couple Claimant 2 £32,300
Child Benefit Income Couple Claimant 3 £37,200
Child Benefit Income Couple Claimant 4+ £42,000
Child Tax Credits (CTC)
Income based Employment & Support Allowance (ESA)
Income based Income Support(IS)
Income based Jobseekers allowance (JSA)
Pension Guarantee Credit
Universal Credit (UC)
Working Tax Credit (WTC)
EST
Annual Gross Household Income (£)
*
*
Please tell us your annual gross household income. Enter numeric values only.
Consent to share your details to check eligibility
*
No
Yes
Please confirm your consent for City Energy Network Ltd to share the data submitted on this page with the Department for Work and Pensions in order to verify you are in receipt of the benefit selected.
Application Details
Project Number
Project Status
Applicant
In Scheme
In Scheme
No
In Scheme
Yes
Is Portal Application?
Is Portal Application?
No
Is Portal Application?
Yes
How did you hear about us?
Text
Facebook
Local Authority Website
City Network Ltd Website
Community Home Solutions Website
Gloucester City Homes
Live West
Eco Power
Word of Mouth
Other
Please provide details of where you heard about us
