Please Read the Guidance Notes Before Filling in This Application Form

Gas Safe Charity

Fund 2016-17

Application Form

/ The Old Co-op Building
11 Railway Street
Glossop, Derbyshire SK13 7AG
Phone: 0300 124 0316
E-mail:

Please read the guidance notes before filling in this application form.

Once you have completed the form and attached all the relevant documents, please email it to:

For office use only

About your home improvement agency / Guidance
Agency name / HIA Title
Address / Mailing Address for Correspondence
Local Authority / LA name
Bank account name / HIA Account Details
Sort Code / Account Number (for BACS payments) / 6 Digit Sortcode & 8 Digit Account Number
Your name / Caseworker Name
Phone number / Landline or Mobile
E-mail address / Email Address
Applicant details
Client's name / Primary client name
Client’s Address / Full postal address
Agency case number / Case number / Reference
Amount requested / Total cost of work including VAT
Client’s age (& date of birth) / Age
Date of birth / This will be used to check eligibility

Please complete the following questions

In order to be eligible for funding the client needs to be from one of the goups below. Please tick which one best describes the client
Is a home owner over the age of 60 and is in receipt of means tested benefit
Is a home owner over the age of 60 and is in receipt of state pension only
Is a home owner over the age of 60 and is disabled
Is a home owner over the age of 18 and is disabled
What type of gas safety work is the funding needed for?
Gas Safety Check
Gas Servicing
Gas Boiler Repairs
Gas Boiler Replacement
Gas Boiler Combustion Analysis
Gas Cooker
Gas Fire
Gas Pipework
Gas Meter
Water Heater
Full cost of the work (please ensure contractor’s quote is attached)
(£)…………..
Any other sources of funding which will be used to pay for the works?
Source / Value (£)

Provide details of any other work carried out at same time (if applicable)

Description of other work to be carried out at the same time (if applicable) / Value (£)
Please provide a brief description below of the purpose that the grant will be used for and some details of the client’s situation and background.

Client declaration

I certify that the information in this application form relating to me and my circumstances is true and correct. By giving the information above I consent to my personal and sensitive personal data to be provided to, used and stored by Foundations Independent Living Trust Limited (“FILT”) and Gas Safe Charity (“GSC”) employees, representatives and any other appropriate person in order to process this application form in line with the GSC Scheme, for analysis and statistical purposes, market research, auditing purposes and for the general promotion of the GSC scheme or FILT. I also accept that I may be contacted in relation to any GSC Scheme or FILT activities.

I agree that I am willing to become a case study: Yes / No / Date
Client signature / Print Name

HIA Declaration

I have attached a quote for the work to be completed

I have made reasonable enquiries to establish the accuracy of the information provided by the client.

I accept liability for repaying any grant that the Trust finds was not eligible due to error or carelessness by this home improvement agency.

I understand it is a requirement of this scheme that, on completion of the work, I send the completion note (provided by FILT) and copy of the contractor’s invoice by email to FILT

Your name / Title
Your signature

Please scan and email this form with the contractor’s quote to:

Registered charity number 1103784 July 2016