Application for Water Support
Scheme to 31 March 2017

Customer Details:
PLEASE COMPLETE IN BLOCK CAPITALS USING BLACK PEN
*mandatory fields
Mr
Miss
Mrs
Ms
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No

In order to apply, please answer ALL questions below by crossing (X) the applicable boxes:

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No
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No
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No
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No
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No
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No
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Declaration to be signed by the Applicant and Advice Worker (if applicable)*

By signing and dating this form: The Applicant confirms that the information provided is up to date and factually correct. The Advice Worker confirms they have seen the documentary evidence verifying the information provided is up to date and factually correct.

If your Sutton & East Surrey Water bill includes Thames Water Sewerage charges please also complete the form on reverse to apply for a discount on these charges as well.

In order to apply for the Thames Water WaterSure Plus Scheme you must complete all sections on this page and the previous page. If you are only applying for Sutton & East Surrey Water's Water Support Scheme you do not need to complete this page.

Financial Statement

Please ensure you include ALL NET MONTHLY Household Income for the entire household

Yes
No
Yes
No
Yes
No
Yes
No

Declaration to be signed by the Applicant (and Advice Worker if applicable)*

By signing and dating this form, you are confirming that the information provided is up to date and factually correct and that authorisation applies to those Schemes specified above.

If you are an advice worker signing the form, doing so confirms that you have seen the documentary evidence verifying the applicant's entitlement to the tariff.

You agree to provide, when asked for, any further information that may be required to confirm you are eligible for the tariff to support your application.

Please return to the freepost address: Freepost SESW WATER SUPPORT
Sutton and East Surrey Water Customer Services Team: Telephone 01737 772000, option 1