Cosy Homes in Lancashire - Enquiry & Referral Form

Cosy Homes in Lancashire - Enquiry & Referral Form

Cosy Homes in Lancashire is a scheme to help households access grant funds to provide free or subsidised insulation and boilers. It has been set up by local authorities in Lancashire and is being delivered on their behalf by Hughes, Firefly Energi and LESS. If you are interested in benefitting from the scheme, please complete the form below and return by e-mail or to the freepost address overleaf. Please also contact us if you need any support in filling it in.

1) Insulation
What do you have and what are you interested in?
Have it / Interested / Not sure
Cavity Wall Insulation
Loft Insulation
Solid Wall Insulation (Internal or External)
Draught Proofing
Anything else? Please list below:

2) Property Details
What type of home do you have? (Tick all that apply)
House Flat Detached Semi-detached
Mid-terrace End-terrace Bungalow Flat Maisonette
Is it primarily?
Brick built Stone built Other
How many bedrooms do you have?
When was your home built (approximately)?
Pre-1900 1900-1929 1930-1949 1950-1965 1966-1974 1975-1981 1982-1990 1991-1995 1996-2002 After 2002 Not sure
Do you own or rent your home?
Own/buying on mortgage Private rented
Council/Housing Association Tied House
Is the property a House in Multiple Occupation? (i.e. you have a private bedroom but share other facilities)
Yes No
3) Flat Details (if you don’t live in a flat go to Section 4)
Is your flat:
Part of a converted house
In a purpose built block (up to 5 storeys)
In a tower block (6 storeys or more)
Above a shop or office
Where is your flat positioned in the building?
Basement Ground Floor Mid Floor Top Floor
How many walls are fully exposed to the outside?
1 2 3 4 / 4) Boiler/Heating Replacement
We may be able to offer you a condensing gas boiler or storage heaters, or a cash contribution towards them, if yours are broken or inefficient.
Do you have a working central heating system?
Yes No
Are you interested in finding out more about a new gas boiler or new storage heaters?
Yes No
5) Personal Details
(These may help to increase the amount of funding available to you, so please answer all that apply)
What’s your date of birth?
Is anyone in the household in receipt of benefits?
State Pension Credit / Child Tax Credit
JSA, ESA, income support / Working Tax Credit
Other (please specify)

Are there children under the age of 18 living in the property?
Yes, their ages are: No
Does anyone in the household have a disability or long-term health condition(s)?
Yes, it’s: No
If yes, how many of the following have been made in the last 12 months related to those condition(s)?
Hospital visits GP visits
6) Energy Bills and Advice
We can also help you with free, impartial energy advice:
How do you pay for your bill?
Direct Debit Pay on receipt Prepayment meter
Would you like advice on how to switch your energy provider or tariff in order to save money?
Yes No
Would you like advice on your fuel bill and any issues with arrears or debt?
Yes No Now please turn over
7) Renewable Energy
We may be able to offer you advice on the government’s Feed-in Tariffs (FITs) and Renewable Heat Incentive (RHI) that could help pay for installing renewable energy generation in your home (e.g. solar panels, heat pumps).
Are you interested in finding out more about renewable energy opportunities? Yes No
Your Contact Details
If you are applying on your own behalf please complete the Client Contact Details, sign the Client Declaration and return it to the address below by post or by e-mail (if returning electronically, a typed signature will be acceptable). We will then be in touch to confirm your details and book you in for a free survey of your property.
If you are applying on behalf of the homeowner/tenant (e.g. you are a family member, support worker, etc) please complete both the Client Contact Details AND the Referrer Contact Details and sign the Referrer Declaration section.
The Cosy Homes in Lancashire initiative, overseen by local authorities in Lancashire, will only use your information for assessing grant eligibility, arranging surveys and other related matters in compliance with the Data Protection Act. Your details will not be used for any other purpose without your consent.
Client Contact Details / Client Declaration
Title: Mr Mrs Miss Ms Other / To the best of my knowledge, the information that I have provided on this form is correct. I consent to my details being shared with partner agencies for the sole purpose of accessing energy efficiency measures and other relevant advice and support available to me.
Signed: x
Date: x
Name: /
Address:
(including postcode) /
Home Phone /
Mobile /
E-mail /

Please only complete the section below if applicable:

Referrer Contact Details / Referrer Declaration
Title: Mr Mrs Miss Ms Other / To the best of my knowledge, the information that has been entered on this form is correct. I can confirm that the client named on this form has consented to their details to be shared with partner agencies for the sole purpose of accessing energy efficiency measures and other relevant advice and support available to them.
Signed:
Date: x
Name: /
In what capacity are you acting on behalf of the home
owner/tenant?
Organisation (if applicable) /
Phone /
E-mail /
Please now return this form to either:
Freepost RTLE-LKRG-LCET
Less (Lancaster District) CIC or
The Storey, Meeting House Lane,
Lancaster, LA1 1TH / For office use - Notes

For office use - UPRN

For help and support please call 0330 606 1488 or e-mail