HHCRO Application.

Title

First Name

Last Name

House Number/Name

Street Name

Town

Postcode

Primary Contact Number

Secondary Contact Number

Best time to contact

Please select the property with the GREEN roof that best matches your home

Detached

Semi-Detached

Enclosed Mid-terrace

Mid-Terrace

Enclosed end-terrace

End Terrace

Bungalow

Flat

Age Of house

How many stories in your home?

How many bedrooms in your home

Please Select your wall type

Solid Wall

Cavity Wall

Timber Wall

Do you have Cavity insulation?

Do you have loft insulation?

Please Select the type of boiler you have in your home

Wall Mounted Boiler

Floor standing boiler

Back Boiler

Is there a fault with the boiler?

Fuel Type

Age of boiler?

Please Select any of the following benefits you receive.

Child tax credit with income lower than £16010

Working tax credit with income lower than £16010

Income Based employment and support allowance (ESA)

Pension Credit

Income Support

Income based job seekers allowance

None of the above

Should you and your property qualify for a boiler replacement, proof of your benefit(s) will be needed, please ensure that you have all pages of you most recent award letter stating your benefit. Surveys will not be booked in without benefit evidence being provided.

Please select the type of application you wish to make.

Boiler replacement

Loft insulation

Cavity wall insulation

Please select your tenancy status.

Homeowner

Private Tenant

Housing association

If you have any additional information/comments you wish to provide, please use the field below.

Is it a combination boiler?

Yes

No

Don’t know