Title MrsMrMissMs
First Name
Surname
National Insurance Number
Agent Id
Postcode
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Town
Telephone number
Email_Address
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How often do you feel cold in your home?* - 1
How often do you feel cold in your home?* - 2
How often do you feel cold in your home?* - 3
Do you struggle to pay energy bills?* - 1
Do you struggle to pay energy bills?* - 2
Do you struggle to pay energy bills?* - 3
Do you have damp or mould in your home?* - 1
Do you have damp or mould in your home?* - 2
Do you have damp or mould in your home?* - 3
How old is your park home property?* - 1
How old is your park home property?* - 2
How old is your park home property?* - 3
How old is your park home property?* - 4
How old is your park home property?* - 5
How long have you lived in a park home?* - 1
How long have you lived in a park home?* - 2
How long have you lived in a park home?* - 3
How long have you lived in a park home?* - 4
How long have you lived in a park home?* - 5
Do you own or rent your park home?* - 1
Do you own or rent your park home?* - 2
Are you a member of any park home or park residents associations?* - 1
Are you a member of any park home or park residents associations?* - 2
Do you have access to the internet?* - 1
Do you have access to the internet?* - 2
How do you heat your water?* - 1
How do you heat your water?* - 2
How do you heat your water?* - 3
How do you heat your water - please specify
Are you billed for your electricity by your park site owner?* - 1
Are you billed for your electricity by your park site owner?* - 2
Is your electric bill calculacted from a sub-meter - 1
Is your electric bill calculacted from a sub-meter - 2
Do you have Liquid Petroleum Gas (LPG)?* - 1
Do you have Liquid Petroleum Gas (LPG)?* - 2
Do you have mains gas supply?* - 1
Do you have mains gas supply?* - 2
Have you been referred to this scheme by the Department of Work & Pensions (DWP)? - 1
Have you been referred to this scheme by the Department of Work & Pensions (DWP)? - 2
Please confirm if you have received and read the Park Homes Warm Home Discount leaflet?* - 1
Please confirm if you have received and read the Park Homes Warm Home Discount leaflet?* - 2
Declaration - 1
Declaration_Accepted_Date Submit Form