Warm Homes Local Grant application

1. Personal Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone *

Email *

Local Authority *

We are only able to provide funding to households in Gloucestershire and South Gloucestershire local authorities

Optional: Nominated Representative

Please complete the below if you would like someone to communicate on your behalf in relation to the processing of your application for grant funding and authorise Severn Wye Energy Agency to disclose to him/her/them any personal data held about you. Please note, a Nominated Representative cannot make decisions on behalf of the applicant, unless they have Lasting Power of Attorney (LPA) for Finance Decisions.

Would you like to appoint a Nominated Representative *

Yes
No

Please note: you will be required to provide evidence later in the application process if your Nominated Representative has Lasting Power of Attorney

2. Property Information

Please indicate your status as the householder *

Owner occupier
Private tenant
Shared ownership

Is your property a listed building, in a conservation area or has any other restrictions? *

Yes
No
Not sure

If yes, please be aware that this may impact the timescales or ability to complete work on your property.

Do you know what type of external walls you have? *

Cavity walls
Solid walls
Other
I’m not sure

Would you consider an air source heat pump? *

Yes
No

What is the Energy Performance Certificate (EPC) rating for your home? *

This scheme can only provide support to properties rated D, E, F or G. Unsure where to find your EPC? Visit https://www.gov.uk/find-energy-certificate and search for your address. If unknown/no EPC available, an EPC will need to be completed to confirm eligibility, and we will arrange for a free EPC to be conducted as part of this scheme.

Does the information in the EPC seem correct? Have any improvement works taken place since it was issued?

If you don’t feel confident interpreting your EPC, give one of our advisers a call and they will be happy to help.

Which of the following best describe the reason you are applying for energy-saving home improvements? *

The actual improvements we will offer you will be based on the most suitable upgrades to your property, which will be identified by the surveys and assessments we conduct.

What changes would you like to see to your home?

3. Finance

Household income

Below, please outline the Annual Gross Income (before any income tax or National Insurance is paid) for each occupant of the household.

Occupant 1 *

Occupant 3

Occupant 2

Occupant 4 (plus any others)

Total for household per annum *

To qualify for the Warm Homes Local Grant, your combined household income (before tax) must be under £36,000. Add the income values above to give the total household income.

4. Health information

Date of birth of eldest resident *

Number of adults (18-64)

Number of adults (65+)

Number of children under 5

Number of children aged 5-18

Please specify any health conditions in the property, including if anyone is pregnant:

5. Evidence

We are required to collect evidence as part of this application to demonstrate that you are eligible for grant funding and/or that the information you have given us is correct. All documents (except passports) must include the name AND address of the applicant. Please do not send original documents. These need to be supplied together with the application form.

Evidence declaration 1 *

I understand that I will be asked to provide these documents for auditing purposes

Personal identification

You must upload a form of ID to prove your identity as the applicant.

For example, a copy of your passport, driver’s license or similar.

Personal identification evidence

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Household income

You will be asked to produce evidence of all gross household incomes. All documents must be dated within the last 3 month or current tax year for annual statements.

For each adult receiving income you must provide EITHER:

Proof of all benefits currently received from the list above (e.g., Latest DWP letter addressed to you or last three months full bank statements containing name and address)

OR one of the following combinations:

Bank statements – all last three months full bank statements, with front sheet containing your name and address
Pension statement from all pensions received: the most recent annual income statement OR your last three-monthly income statements if you are notified monthly
Payslips – last 3 months’ payslips.
P60 – Lastest P60 form for each income received.
Tax Return – Current tax year signed by accountant or latest tax year self-assessment.

Household income evidence

Drag & Drop Files, Choose Files to Upload You can upload up to 15 files.

Property details

Proof of number of adults at the address e.g. council tax letter, tenancy statement or mortgage statement
If you own the property, you will also need to provide us with a mortgage statement in your name OR Title Deeds for the property

Property evidence

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

6. Declaration

I confirm that I have the permission of all individuals within the household to provide their information and understand that the details and data I have provided will be added to Severn Wye Energy Agency’s database. I consent to Severn Wye sharing the information provided with the UK Government’s Department for Energy Security and Net Zero, Stroud District Council and their appointed contractor. I acknowledge that Stroud District Council on behalf of my local authority may use the information contained in this application for the detection and prevention of fraud.

I declare that to the best of my knowledge the details I have provided are correct, and that I will be asked to provide evidence of income and/or health conditions stated within this form.

WARNING: if you knowingly make a false statement, you may be liable to prosecution.

By signing I confirm that the information I have provided is accurate and I accept the declarations above.

Print name *

Signature *

Clear Signature

Communications Preferences

Severn Wye may contact you in the future for information to advise you on further ways you could save money and other grants you may be entitled to. See the Data Privacy Statement for more information.

Communications

I am happy to be contacted about future support I may be eligible for.

Research and evaluation

To assist in the administration of the Warm Homes Local Grant scheme, Stroud District Council would like to process your personal data in order for Stroud District Council, DESNZ or their appointed contractors to contact you to participate in further research and evaluation activities.

Do you consent to Stroud District Council, DESNZ, or their appointed contractors, using your provided contact details to recontact you for the purpose of research and evaluation related to the installation received under this scheme. Your consent is not required for the installation to take place. You have the right to withdraw consent at any time by contacting Stroud District Council or DESNZ at any time, using the contact details provided in the privacy notices.

Research

I am happy to be contacted to help with research and evaluation if required.