Enquiry Ref No: West Lancashire Borough Council Private Sector Housing Team 61 Westgate Skelmersdale West Lancashire WN8 8LH ENQUIRY FORM FOR THE WEST LANCS WINTER WARM SCHEME NOVEMBER 2014 to MARCH 2015 THIS SCHEME IS ONLY AVAILABLE TO OWNER OCCUPIERS WHO DO NOT HAVE A PLAN THAT COVERS BOILER SERVICING AND REPAIR (FOR E.G. A BRITISH GAS BOILER COVER PLAN). IMPORTANT NOTE: The funding available for the West Lancs Winter Warm Scheme is limited therefore applications will be dealt with in the order they are received. The scheme will close on the 31st March 2015 unless the funding has been fully committed before this date The information provided on this form will help the Council deal with your enquiry as quickly as possible. You will be contacted by the Council to discuss your enquiry in due course. DO NOT START ANY WORKS UNTIL FUNDING HAS BEEN CONFIRMED Please complete all sections of the form and print clearly using BLOCK CAPITALS. Where required place a tick (√) or number in the appropriate box. If you have difficulty in completing the form please contact the Council’s Private Sector Housing Team for assistance on 01695 585 279. NOTE: The above address is NOT open to the public. The form can be returned by post to the above address or by email to [email protected]. Alternatively the form can be handed delivered to one of the Council’s Customer Service Points at 52 Derby Street, Ormskirk, L39 2DF or Unit 142, First Floor, The Concourse, Skelmersdale, WN8 6LN YOUR APPLICATION WILL NOT BE PROCESSED UNLESS YOU ENCLOSE PROOF OF THE BENEFIT YOU ARE CLAIMING WHEN RETURNING THE FORM PART A APPLICANTS PERSONAL DETAILS A1. Name ………………………………………………………………………… A2. Address …………………………………………………………………………. ………………………………… Postcode ………………………….. A3. Date of Birth ……………………………… Age ………………………………….. A4. Daytime telephone number ………………………………………………………… A5. Email address: ………………………………………………………………………. A6. I am the owner occupier of the property and live there as my only home: A7. How many people over the age of 18 live in the property? A8. How many children aged 16 and under live in the property? ……………………. A9. How many children aged 14 and under live in the property? ……………………. □ ……………………. A10. I confirm that I have not had my heating system serviced in the last 12 months: □ A11. I confirm that my heating system is not covered by a service repair plan □ (e.g. a plan with British Gas or other provider that covers boiler repairs and includes an annual service) PART B PROPERTY DETAILS B1. When was the property built? (approx year) B3. What type of property is it? (please tick) ………………………………. A detached house □ A semi-detached house □ A bungalow □ A terraced house □ A flat □ A houseboat** □ A caravan* □ *Funding will only be provided for servicing/repairing gas heating appliances in caravans where the caravan has a residential pitch in West Lancashire and is the occupiers’ only home. **Funding will only be provided for servicing/repairing gas heating appliances on houseboats where the houseboat has a residential mooring in West Lancashire and is the occupiers’ only home. If none of the above then please describe property ………………………………………………. …………………………………………………………………………………………………………… PART C C1. WORK DETAILS Please tick the boxes that are relevant to the work you would like to be carried out: Gas boiler service □ Gas boiler repair □ *Gas fire service □ *Gas fire repair □ Oil heating system service** □ Replacement gas boiler □ *If the gas fire cannot be repaired at a reasonable cost or is condemned, it will not be replaced under this scheme. **We cannot guarantee that we can service an oil heating system as this is specialist work. However, we will attempt to source a contractor and obtain a quote for the work. Agreement to fund will depend on the cost. C2. Please provide the make and model of your boiler/fire along with the date it was installed. …………………………………………………………………………………………………. …………………………………………………………………………………………………. C3. Have you had any of your heating appliances serviced/repaired or replaced in the last 12 months? If yes, please state which appliance was serviced, the date and who carried out the service: ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. PART D D1. ASSESSING YOUR ELIGIBILITY You must meet one of the following eligibility criteria to be eligible for funding: I am aged 65 or over and in receipt of one of the following benefits (please tick all the boxes that apply) Income Support □ Income Based Job Seekers Allowance □ Income based ESA □ Guarantee Pension Credit □ Working Tax Credit □ Universal Credit □ □ Industrial Injuries Benefit □ (based on a relevant income of less than £15,860 per year) War Disablement Pension (must include mobility supplement or constant attendance allowance) (must include constant attendance allowance) I have dependent children aged 14 and under and am in receipt of one of the following benefits (please tick all the boxes that apply) Income Support □ Income Based Job Seekers Allowance □ Income based ESA □ Universal Credit □ Working Tax Credit □ Child Tax Credit □ (based on a relevant income of less than £15,860 per year) War Disablement Pension (based on a relevant income of less than £15,860 per year) □ (must include mobility supplement or constant attendance allowance) Industrial Injuries Benefit □ (must include constant attendance allowance) I am a single person/couple aged under 65 without dependent children and I am in receipt of one of the following benefits (please tick all the boxes that apply): Income Support □ Income Based Job Seekers Allowance □ Income based ESA □ Universal Credit □ Working Tax Credit □ Child Tax Credit □ (based on a relevant income of less than £15,860 per year) Guarantee Pension Credit (based on a relevant income of less than £15,860 per year) □ War Disablement Pension □ (must include mobility supplement or constant attendance allowance) Industrial Injuries Benefit □ (must include constant attendance allowance) D2. Do you or anyone who lives with you, suffer from one of the following conditions? Please tick all that are relevant. Arthritis (osteo & rheumatoid requiring regular treatment & review) Cancer Cardiovascular disease (e.g. heart disease, stroke) Diabetes (in particular type 1) Mental illness (e.g. depression [& receiving treatment], schizophrenia, bipolar disorder) Reduced Mobility Respiratory disease (e.g. COPD, emphysema, chronic bronchitis, severe asthma) Terminal illness Other (Please specify) D3. D4. In relation to the conditions listed in D2, please state: The number of times you have visited your GP in the last 12 months …………. The number of times you have been to hospital in the last 12 months …………. The name and address of your GP: ……………………………………………………………………………………………….. ……………………………………………………………………………………………….. ……………………………………………………………………………………………….. PART E E1. MONITORING Have any of the following agencies helped you with this form? Help Direct Citizens Advice Bureau Local Authority Housing Team Home Improvement Agency Fire Service GP Hospital Discharge Team Community Matron Palliative Care Social Care Other Self Referred Declaration I certify that the above information to the best of my knowledge is correct. Some of the information you provide will be shared with Lancashire County Council’s Public Health Team who are providing the funding for this scheme. The information in D2 and D3 is being gathered to track whether this scheme has helped people with long-term illnesses reduce the number of times they need to visit their GP or hospital by helping them keep warm. All information will be sent in an anonymous format and Lancashire County Council/West Lancashire Borough Council may contact you following the closure of the scheme to find out if the work carried out has been of benefit to you. Signed: …………………………………………………….. Date: ………………………………… Ethnic Origin Monitoring Form Arab □ Asian Bangladeshi □ Asian Chinese □ Asian Indian □ Asian Pakistani □ Any other Asian Background □ Black African □ Black Caribbean □ Any other Black Background □ Mixed White and Asian □ Mixed White & Black African □ Mixed White & Black Caribbean □ Any other Mixed/Multiple Ethnic Background □ White British/English/Welsh/Scottish/Northern Irish □ White Gypsy/Traveller □ White Irish □ Any other White Background □ Other □ Prefer not to answer □