Here2Help Scheme Customer Application Form
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- Dinah Willis
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1 Customer
2 Billing Reference: Property Reference: Account Holders Details First name: Surname: Additional Contact Details (If you would also like us to discuss your application with somebody else) First name: Surname: 1 st Line of address: 1 st Line of address: Postcode Landline Number: Mobile Number: address: Postcode Landline Number: Mobile Number: address: Date of Birth: dd / mm / yyyy Date of Birth: dd / mm / yyyy Relationship to Account Holder: Data Protection Act We produce statistics for use by other organisations (e.g. Government departments, local authorities, Dee Valley Water and Citizens Advice). These statistics are anonymous and nobody outside of these organisations will be able to find out that you have asked for help with your payments or obtain any of your personal information, for example your home address. I am happy for you to use my anonymous data in this way: Yes No Please tick We would like to contact you in the future to find out what you thought of the service you have received here. This helps us to improve our service for others. I am happy for you to contact me to find out what I thought of the service: Yes No Please tick 2
3 1. YOU AND YOUR HOUSEHOLD Total number of people in household (aged 18+): Number of dependent children: 13 and below: 14 18: Number of vehicles at the property: 2. MONTHLY INCOME You Income from employment: (after tax and N.I. deductions) JSA / ESA / IS / Pension credits Housing benefit Council tax benefit Tax credits Child benefit Universal credit Other benefit: (DLA / PIP / mobility / carers allowance) Pension (private / state): Money from other people: Any other income: 3. HOUSEHOLD OUTGOINGS TOTAL HOUSEHOLD INCOME: Please tell us the monthly figure that you pay out for the below: Your Partner Mortgage / Rent: Gas: Second Mortgage / Secured loan: Electricity: Ground rent / service charges: Water: Buildings / Contents Insurance: Other fuel (coal, oil, propane, gas etc) Magistrates Court fines: Property maintenance: Council tax: Phone, broadband and television: Maintenance and child support: HP agreements (appliances / white goods) TV Licence: TOTAL HOUSEHOLD OUTGOINGS: 3
4 4. PERSONAL OUTGOINGS Please tell us the monthly figure that you pay out for the below: Food: (home / school / work): Mobile phone: Clothing: Hairdressing: Housekeeping: Gambling: (lottery, pools, sports) Other housekeeping: Veterinary: (bills / insurance) Cleaning and toiletries: Health: (dentist / glasses / prescription / insurance) Newspaper and magazines: Pocket money and school trips: Cigarettes. tobacco & sweets: Activities: (leisure / sport / evenings out / gym) Alcohol: Gifts: (christmas, birthdays, charities) Laundry and dry cleaning: Holidays: Nappies and baby items: Care: (adult / children) Pet food: Other outgoings: Travel: (public transport / petrol / diesel) TOTAL PERSONAL OUTGOINGS: 5. PRIORITY DEBTS If you have any of the below debts please insert them here: Amount owed Mortgage / Rent arrears: Council tax arrears: Gas / Electricity arrears: Outstanding Fines: Maintenance / Child Support: TV Licence arrears: Hire purchase or conditional: Tax / National Insurance: Student loan / bank loan / secured loan: Any other debts: TOTAL MONTHLY PAYMENTS TOWARDS DEBT: Monthly payment 4
5 6. DISPOSABLE INCOME What is your disposable income per month (money you have left over) after taking into account your monthly outgoings and your priority debts? 7. ADDITIONAL FACTORS What is your employment status? (Part-time employed; Agency/Intermittent employed; Zero hours employed; Employed but below minimum wage; Retired; Student; Unemployed; Self-employed) Additional Information: Government Benefits Please tick if any of the below apply: I am in receipt of a means tested benefit: Are you waiting for an award decision or appealing against a decision not to be awarded a means tested benefit: If you have ticked any of the boxes opposite, please provide further information: Disabilities Does anybody in the household receive a disability benefit?: Is anybody waiting for an award decision or appealing against a decision not to award a disability benefit: Dependants I have a dependent child or a dependent elderly relative living at the property: Restrictions I have a cap applied to my benefits: Please provide details of any restrictions: I am subject to bedroom tax: (One bedroom) I am subject to bedroom tax: (Two bedroom) I am subject to housing benefit deductions because of a non-dependant: 5
6 Water arrears I am in Water arrears of: Please provide further information: ,000 1, ANY OTHER INFORMATION Please provide us with any other information that you feel will support your application? 9. PAYMENT OPTIONS How would you like to pay your water bill? Direct Debit: Watercard: How often would you like to pay your water bill? Weekly: Fortnightly: Monthly: 10. CONFIRMATION Please provide any evidence to support the statements that you have made in this application. (Bank statements, benefit statements, tenancy agreements, monthly bills etc.) Signed: Date: dd / mm / yyyy Please return your completed application form to: Dee Valley Water plc, Packsaddle, Wrexham Road, Rhostyllen, Wrexham, LL14 4EH 6
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