• Tackling fuel poverty in the West Country
  • information@warmwest.org.uk
  • 01656 747 623

Gas Application Form

Gas Connection Grant Application

Find out if you qualify for a grant before you pay for a new connection by completing our gas grant application form.

For assistance with this form or uploading supporting documents you can call our helpline: 01656 747623 or you can email us at: information@warmwest.org.uk

Part A

All fields marked * are required. You must answer all questions in Part A, B and C in order for us to assess your eligibility. Failure to answer any question may delay your assessment.

Title *
    If Other:

Name *

Address *

Postcode *


Your Email *

Address for the Gas Supply *

Postcode *


Please check the appropriate box for each question in Part A

1. Do you live at the gas supply address? *
YesNo (You must live at the house to claim a grant)

2. Are you currently:

Building your house *

Renovating your house *

3. Are you:

A. the property owner? *
YesNo (If yes, please provide evidence of ownership)

B. an occupier of the property? (you live in home but do not own or rent it) *
YesNo (If yes, please provide evidence of residency)

C. a private tenant? *
YesNo (If yes, please provide evidence of tenancy agreement)

D. the tenant of a housing association or local authority? *
YesNo (If yes, please provide evidence of tenancy agreement)

(if yes - please select a copy of a requested document to upload)

For tenants: please provide Landlord’s Name/Address/Telephone number in the box below:


Correspondence Address


4. How many people (including children) are in your household?

Number of Male adults and their ages

Number of Female adults and their ages

Number of Children and their ages

5. Is anyone usually at home during the day? *

6.a. What is the combined income over a year, after any tax and National Insurance is paid, of all the people living in your home? (Please include all wages, benefits, pensions, interest on savings or other any other money received – after tax and any National Insurance payments.)
Income – after tax: Week, or month or year

Each Week £

Each Month £

Each Year £

6.b.What are your housing costs and do you receive any help to pay your housing bills?

Housing costs each year

Mortgage £

Rent £

Council Tax £

Housing help each year

Mortgage support £

Housing Benefit £

Council Tax Reduction £

7. Please explain if:

Your surname differs from the name on your evidence

Your address differs from the address on your evidence

8.a. How do you pay for your household energy? *
QuarterlyDirect DebitPre-payment

8.b. How much do you pay for your household energy in a year?

Select your Existing Fuel

If your fuel is Economy 7 please give cost of Day and Night units
Unit cost day £
Unit cost night £

Standing charge each year (if this applies)

Cost per kWh \ litre \ tonne

Part B

Statement of Benefits

Where do you live? *

Your benefits

Please check each box if you claim any of the following benefits:

Pension CreditIncome Based Job Seeker’s AllowanceWorking Tax Credit (an Upper Earnings Limit applies)Child Tax Credit (an Upper Earnings Limit applies)Income Related Employment and Support AllowanceIncome SupportCouncil Tax Reduction (for Wales residents only)Universal Credit

Your husband's, wife's or partner's benefits (Wales only)

Please check each box if your partner claims any of the following benefits (Wales only):

Pension CreditIncome Based Job Seeker’s AllowanceWorking Tax Credit (an Upper Earnings Limit applies)Child Tax Credit (an Upper Earnings Limit applies)Income Related Employment and Support AllowanceIncome SupportCouncil Tax ReductionUniversal Credit

(Copies of your benefit award letters will be required, please select a file to upload)

Part C

1. When was your home built? *
Pre 19001900-19291930-19491950-19661967-19751976-19821983-19901991-19951996-20022003-2006Post 2007

2. What type of home do you have? *

3. Is your home: *
DetachedSemi-detachedEnd terraceMid-terraceFlat

4. Floor Level (for flats and maisonettes only)
Top floorMid floorGround levelBasement

5. How many storeys does your home have:

6. How many bedrooms in the property:

7. How many living/dining rooms in the property:

8. How much of your home is double glazed: *
NoneSome (up to 25%)Half (50%)Most (75%)All (100%)

9. Are your window frames made of: *
WoodPlastic / UPVCMetal

10. What type of roof does your home have? *
FlatPitched - No AccessPitched RoofPitched (Thatch)Pitched / Loft AccessAnother Dwelling Above

11. What is the depth of loft insulation? *
½”/12mm1”/25mm2”/50mm2.5”/75mm4”/100mm6”/150mm8”/200mm10”/250mm12”/300mm12+”/300mm+Flat roof insulationNoneUnknown

12. Are your external walls: *
Solid BrickCavityTimber FrameConcreteStoneOther

(if other please specify)

13. What wall insulation do you have: *
No InsulationFilled Cavity InsulationInternal Wall InsulationUnknownAs BuiltExternal Insulation

Part D

1. What is your main heating system in your home? *
Standard BoilerWarm Air SystemCondensing BoilerStorage HeatersCombi BoilerRoom Heaters / FiresCondensing - Combi BoilerOther

If 'Other' please specify:


2. What fuel does your main heating system use? *
AnthraciteCoal (open fire in grate)Coal (closed room heaters)Wood chipsWood logsWood pellets (bulk supply)LPG/Bottled gasLPG Bulk (Tank)Heating oilElectricity – on peakElectricity – off peak (night storage heaters)

3. What controls does your heating system have:
No controlsHeater/Fire thermostatProgrammer and Room thermostatRadiator valve thermostatManual Charge ControlAutomatic Charge Control

4. If you have a boiler, please specify the make/model number of your boiler:



5. Is your boiler:
Wall mountedFloor standingBack boiler

Part E

Questions 1 to 5 below refer to how you heat your hot-water in your home:

1. How do you heat your hotwater in your home: *
From main heating system (boiler)From secondary heatingBack boilerElectric Immersion (off-peak)Instant Electric water heatingElectric Immersion (on-peak)

2. Cylinder size: *
No CylinderNormal 90 - 130 litres (up to 90cm / 36' tall)Medium 131 - 170 litres (between 90cm / 36' to 135' / 54' tall)Large > 170 litres (over 54' tall)No Access

3. What is your cylinder insulation type: *
No insulationFactory fitted insulation (Solid Foam)Hot Water Tank Jacket

4 What thickness is your cylinder insulation: *
None12mm25mm (Factory fitted - yellow)35mm38mm50mm (Factory fitted - Green)80mm120mm160mm

5. Does your cylinder have a Thermostat: *

Part F

Do you have any renewable technology in your home? *

If yes, please state type:
Solar PVSolar ThermalAir Source Heat PumpOther

Part G - If you already have a quotation from Wales & West Utilities Ltd please enter the details

CRM Ref:

Quote Value excluding VAT

Quote Value including VAT

Date Quotation issued

Date Quotation valid until

Please enter these characters in the box below: *

By submitting this electronic form I give permission for the information on this form to be used by Warm Wales and our partners for the purpose of this project. The information may be recorded by Wales & West Utilities and used for reporting to Office of Gas & Electricity Markets (OFGEM) under the current regulations.

This information will not be given to other companies or agencies and will be held or used in accordance with the Data Protection Act 1998.

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