Household questionnaire

About you and your household

Your name

Address

Postcode

Telephone number

Email address

Number of adults living in your household and ages

Are you a single parent?

Yes No

Length of time in property

Age of property

Mobile number

Date of birth

Number of children living in your household and ages

Is there someone in this home that you provide care for?

Yes No

If yes, what age are they?

Tenure

Select tenure type

Type of property

(Select as many property types as is applicable)

Detached Bungalow Mid-terrace Semi-detached End terrace Flat Other

Council tax band

Number of rooms

Number of storeys

Wall insulation

Floor insulation

Loft insulation

Is there an open chimney?

Yes No

Is/are the fire/s in use?

Yes No

Ventilation (Extraction)

Bathroom

Kitchen

None

Number of bedrooms

Main build type

Floor type

Roof type

Draughts and condensation

How many open chimneys?

Is there any water ingress in the property?

Yes No

Dampness / mould

Locality of ingress/dampness/mould

Primary fuel

Heating controls

Are these heating controls working?

Yes No

Secondary heating

If boiler, what age?

Thermostat temperature

Are storage heaters and their controls working, if any?

Yes No

Water heating

Are there any faulty appliances

Yes No

Are there any appliances older than 10 years?

Yes No

Are LEDs fitted?

Yes No

Are you aware of the savings by converting to LED, even from low energy lightbulbs?

Yes No

Are you aware where LEDs can be purchased from and the likely cost?

Yes No

Fuel Suppliers

Electricity supplier

Tariff Name

Reading 1

Reading 2

Consumption data (estimate / actual)

Meter 1

Standing charge (rate 1)

Payment method

Text 2

Standing charge (rate 2)

Do you know how to read your electricity / gas / other fuel meter?

Yes No

Cost of electricity (per week)

Cost of other fuel (per week)

Cost of electricity (per month)

Cost of other fuel (per month)

Cost of electricity (per year)

Cost of other fuel (per year)

Fuel provider

Date

Do you have any energy debts?

Yes No

Are you able to keep your home affordably warm and comfortable?

Yes No

Last fill

Unit rate at last fill

If yes, please give details. We work with Citizens Advice to support people reduce debt

Are there any home safety issues that we can help with?

Trip & slip hazards

Faulty smoke & carbon monoxide alarms or none present

Personal circumstances to determine government support level

Age of bill payer

Health conditions of 1 or more people

Actual net income in

Registered medical practice

Savings of more than £28,000

Yes No

Pension Credit

Yes No

Working Tax Credit (with an income of £15,860 or less)

Yes No

Income-based Job Seeker's Allowance

Yes No

Child Tax Credit (with an income of £15,860 or less)

Yes No

Income Support

Yes Yes

Income-Related Employment Support Allowance

Yes No

If you receive Income Support, income-based Jobseeker's Allowance or income-related Employment Support Allowance one of the following must also apply:

You have a child under 16

Yes No

You get Child Tax Credit including a disability element

Yes No

You get a Disability Premium

Yes No

You have a Work Related Activity or Support Component (with income-related Employment and Support Allowance)

Yes No

You have a child under 20 in full-time education (not university)

Yes No

You get a Disabled Child Premium

Yes No

You have a Pensioner Premium

Yes No

If you are in receipt of Working Tax Credit one of the following must also apply:

You are 60 years of age or over

Yes No

You have a child under 20 in full-time education (not university)

Yes No

You have a Disabled Worker Element

Yes No

Total income

Childcare costs, if any

You have a child under 16

Yes No

You have a Severe Disability Element

Yes No

Would you like to be referred for an income maximisation check by the financial inclusion team at CnES?

Yes No

Housing costs – mortgage or rent payments

Is there anyone in the household who would benefit from low cost home ownership?

By submitting this form I confirm that I consent to my data being held under the terms of the Tighean Innse Gall Fair Processing Notice.

I consent

About you and your household

Tenure

Type of property

Property details

Heating system

Appliances

Lighting

Fuel Suppliers

Other fuel type

Home safety

Personal circumstances to determine government support level

Check benefits