Warm Home Discount 24-25 Scotland Name * First Name Last Name Email * Phone (###) ### #### What is your address? Address 1 Address 2 City State/Province Zip/Postal Code Country Is someone helping you fill this form in? * Yes No Please select the support you are receiving below * More than one option can be checked Savings element of Pension Credit Income Related Employment and Support Allowance (ESA) which includes a Work Related Activity or Support Component Income based Job Seekers Allowance (JSA) Income Support Universal Credit Gross Annual Household income (before tax and deductions) less than £18,723 Child Tax Credit (CTC) with an annual income not exceeding £18,723 Housing Benefit or House Payment if receiving Universal Credit Disabled Child Premium/Element Disability Premium, Enhanced Disability Premium or Severe Disability Premium Pensioner Premium or Higher Pensioner Premium or Enhanced Pensioner Premium (or Universal Credit equivalent) Limited Capability for work element with or without Work Related Activity element (as part of Universal Credit) Disability Living Allowance (DLA), Personal Independence Payment (PIP), Attendance Allowance (AA), Adult Disability Payment (ADP) or Child Disability Payment (CDP) or Registered Disabled State Pension Maternity Exemption Certificate(MATEX) OR Medical Exemption Certificate(MEDEX) You or a household member have parental responsibility for a child under the age of 18 years who lives in the same household and is in full time education None of the above None of the above Other If you answered other, please give further details below Thank you!
