8. Are you, or someone in your household, receiving any of the following benefits or tax credits? (Please tick all that apply.)
8. To qualify for this scheme, someone in your household must be receiving at least one of the benefits or tax credits listed.
You must provide a photocopy of the latest ‘notice of entitlement’ for the benefits or tax credits.
The ‘notice of entitlement’ must be less than one year old for a benefit or less than six months old for a tax credit.
If you do not have a notice you can get a replacement by contacting your council or local benefit or tax credit office. (See ‘Useful contacts’ on page 5.)
10. We need to know the name of the person with the medical condition.
11. Please tell us the medical conditions the person has by ticking all the relevant boxes. Important - If you tick one of the named conditions listed at a) to g), please give us a copy of your repeat prescription form or a doctor’s certificate explaining your condition and why you need to use extra water. You can ask for copies of these from your surgery, clinic or hospital. If you do not have the prescription or certificate, please provide some other evidence that you have the condition and why you need to use extra water. OR If you tick h) ‘Another condition’ you must include a doctor’s certificate or letter from a GP or hospital consultant. The letter or certificate must say:
• the name of the patient;
• the condition they have which meansthey have to use a lot of extra water;
• the date the certificate or letter was issued; and
• the name, position and address of the GP or consultant.
12. Please tell us who we can contact to confirm this condition (for example, a doctor or hospital consultant).
|Name||Date of Birth|
(Continue on a separate sheet of paper if necessary.)
13. You should tick this box if the person receiving benefits is responsible for and claims Child Benefit for three or more children who live at the address on the
14. Please provide the full name and date of birth for each child.
You must provide a copy of the latest ‘notice of entitlement’ to Child Benefit for each child you list here.
Alternatively you can provide a copy of a recent bank statement listing your current entitlement and payments.
If you cannot find your ‘notice to entitlement’ to Child Benefit, please contact the Child Benefit Centre (see ‘Useful contacts’).
Water company: Sutton & East Surrey Water plc. Telephone: 01737 772000
You can get replacement or up to date ‘notices of entitlement’ from the following authorities:
|Name of benefit or tax credit||Authority|
|Income Support • Jobseeker’s Allowance • Pension Credit||Please contact your local Department for Work and Pensions|
|Working Tax Credit • Child Tax Credit||Please contact your local Tax credits office|
|Housing Benefit • Council Tax Benefit||Your local authority (council)|
|Child Benefit||Child Benefit Office Phone: 0845 302 1444|
Tick as appropriate
How did you find out about this scheme?
The information I have given is correct to the best of my
knowledge and I understand that if I provide any
information which is false, you may refuse to consider
If my circumstances change and it may affect my claim, I will tell you straight away.
I give the authority who gives me benefit or tax credit permission to give you any information to confirm the information I have provided.
If I have made a claim because of a medical condition, I give the medical professional who knows about that condition permission to give you information about the condition and why I need to use more water, to confirm the information I have provided.
If I pay my sewerage charges to a different company, I give you permission to pass on the details I have provided so that you can also consider my sewerage charges under this scheme.
Warning If you deliberately give us misleading information you are committing a criminal offence and could be prosecuted.
I confirm the following: