(Note: on submitting your completed form, if you have provided a valid email address above you will automatically receive a copy of your completed form).

Address of property that requires assistance

Please enter your post code in the box below and then click on the "Lookup address" button. If your address is NOT SHOWN in the list or is incorrect, you will need to type your address in the boxes provided. In this case please supply as much information as possible.

Post code Please input your post code using capitals and include a space between the first and second parts e.g. DN17 5TY.


Prefix e.g. first floor flat.
House name/number
Street
Town/Village
County

Is the above address the same as your home address?

Yes No

Your address (if different from above)

HomeAddress
Please enter your post code in the box below and then click on the "Lookup address" button. If your address is NOT SHOWN in the list or is incorrect, you will need to type your address in the boxes provided. In this case please supply as much information as possible.

Post code Please input your post code using capitals and include a space between the first and second parts e.g. DN17 5TY.


Prefix e.g. first floor flat.
House name/number
Street
Town/Village
County

Occupancy details

Please indicate the tenure of the property

If you are living at the property, what date did you move in?

Property details

Approximate age of property

Window type

Heating type

Energy provider

Energy efficiency improvements required

Please indicate if any of the following are missing from the property, have been condemned or not working

Cavity Wall Insulation
Central Heating System
Loft Insulation
Renewables
Solid Wall Insulation
Warm Front Client Contribution

Solid Wall Insulation - House built before 1930 have solid brick walls with no cavity in between that can be insulated. External or internal cladding would be required.

Warm Front (Top Up) Client Contribution - If you have been awarded a Warm Front grant the costs of the work may exceed the grant maximum. Help may be available with the client contribution.

Please give details of your Warm Front contribution

Insulation measures

If you are enquiring about insulation measure and are not over 70 or in receipt of a qualifying benefit then the council can offer insulation measures through its discount scheme.

Please select the appropriate box for a free insulation quote

Cavity Wall
Loft

Home improvements/repairs required

Please enter full details of any home improvements required

Children

Are there any children living in the property?

Yes No

If Yes, please give their date(s) of birth

Child's Date of Birth

For multiple children please select the “Add” button above.

Basic financial details (allowances/benefits)

Do you or your partner receive: (please tick all options that apply)

Child Tax Credit*
Council Tax Benefit
Disability Living Allowance
Guaranteed Pension Credit
Housing Benefit
Job Seekers Allowance (with Disability Element)
Income Support
Working Tax Credit*
Working Tax Credit (with Disability Element)

(* and household income is less than £15,460 per year)

If you are not in receipt of one of the benefits listed please state below which benefit you do receive or confirm no benefits

Mortgage details

Do you have a mortgage

Amount outstanding

Estimated value of property

Declarations and consent

Declaration *

I fully understand that if I give false information my enquiry will be cancelled.

Information sharing *

By completing and submitting this form to the Home Improvement Team, I consent to North Lincolnshire Council sharing the information I have given with service providers who can maximise my entitlement to all council and partner services and/or organisations.

Please note - The information you provide on this form will be shared in accordance with the Council’s Data Protection Sharing Strategy.

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