WaterSure Tariff

Full name

Contact number

Email address

Postcode

Pick an address

Address

Town or city

County

Postcode

Country

Customer number (you can find this on your water bill)

Current meter reading

Are you, or someone in your household receiving any of the following benefits or tax credits?

Income Support Income–based Jobseeker's Allowance Income–based Employment and Support Allowance Housing Benefit Child Tax Credit (other than just the family element) Pension Credit Working Tax Credit Universal Credit

Please give the name and National Insurance number of the person who receives one or more of the above benefits or tax credits

You must provide a photocopy of the latest 'notice of entitlement' for the benefits or tax credits

Applying for WaterSure because

Fill in this section if you are applying because of a medical condition

The name of the person in your household who has a medical condition that means they have to use a lot of water

Which of these medical conditions do they have?

Another conditon which means they have to use a lot of extra water (please tell us the name of this condition)

Please give the name and address of the doctor or hospital consultant who knows about this condition.

A copy of your repeat prescription form or a doctor's certificate explaining your condition and why you need to use extra water, and date prescription or certificate was issued.

If you don’t have a copy of a repeat prescription form or a doctor’s certificate available, you can proceed to the next step. We reserve the right to check for evidence at a later date.

Fill in this section if you are applying because you have a large family

I confirm that the person who receives benefits or tax credits is responsible for, and claims Child Benefit for, three or more children under 19 who live with them permanently.

Yes

Please give the full names and dates of birth of these children

A copy of the latest 'notice of entitlement' to Chlld Benefit for each child you list here.

Declaration

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 my claim. If my circumstances change and ii 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, my letter gives you permission to pass on the details I have provided so that you can also consider my sewerage charges under the WaterSure scheme. Warning! If you deliberately give us misleading information you are committing a criminal offence and could be prosecuted. I confirm the following: A member of my household meets the conditions for help under the WaterSure scheme. I only use a hosepipe or watering can to water my garden. My household does not have an auto-filling swimming pool or pond which holds over 10,000 litres of water. I do not receive any help towards the cost of water from the health authority.

Your name

Date

Name of the person receiving benefit (or who has the medical condition).