Energy Support Referrals

First Name

Last Name

Date of Birth

Address

Postcode

Telephone

Preferred Method of Contact

Email SMS Telephone Direct Mail

How many adults in your household?

How many Children in your household?

Name of Referral Agency supporting your application

Contact details of Referral Agency

Supporting statement

Please confirm if the following statements are true:

I have a pre-payment meter I receive a bill for my electricity and/or gas I have a smart meter for my gas I have a smart meter for my electricity

What is your electricity meter serial number

If you have a prepayment meter where do you usually top-up?

Online or via my app At the Post Office At a Paypoint Store Other

Who is your energy supplier for Gas?

Who is your energy supplier for Electricity?

Evidence of your pre-payment meter balance or a copy of your most recent energy bill is required. Please provide a photo of your pre-payment meter with your meter serial number clearly visible or a photo of your energy bill with your energy account number and balance clearly visible.

Please tick the following statements that apply to you

I receive a means-tested benefit I receive a health-related benefit

Please note: We prioritise households that may be in a vulnerable situation. Please tick the following statements that applies to you. (You may be required to supply evidence)

I have a health condition made worse by the cold I have been affected by domestic abuse I am a care leaver living independently for the first time I have a long term health condition I live in a hard to heat home I am a refugee / asylum seeker English is not my first language

Are you happy for Energy Manage to send you energy advice and information?

Yes No