Gas Safe Charity
Fund 2014-15
Application Form
The Old Co-op Building
11 Railway Street
Glossop, Derbyshire SK13 7AG
Phone: 0300 124 0316
E-mail: info@filt.org.uk
Please read the guidance notes before filling in this application form.
Once you have completed the form and attached all the relevant documents, please send it to the
email address shown above.
For office use only
Fund reference number (for office use)
About your home improvement agency
Guidance
HIA Title
Agency name
Mailing Address for
Correspondence
Address
LA name
Local Authority
HIA Account
Details
6 Digit Sortcode &
8 Digit Account
Number
Caseworker Name
Landline or Mobile
Email Address
Bank account name
Sort Code / Account Number (for
BACS payments)
Your name
Phone number
E-mail address
Applicant details
Client's name
Primary client name
Client’s Address
Full postal address
Case number /
Reference
Agency case number
Total cost of work
including VAT
Amount requested
Client’s age (& date of birth)
This will be used to
check eligibility
Age
Date of birth
Registered charity number 1103784
July 2014
1
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 21 and is disabled
What type of gas safety work is the funding needed for?
Gas Safety Check
Gas Servicing
Gas Boiler Repairs
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)
Registered charity number 1103784
July 2014
Value (£)
2
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.
Registered charity number 1103784
July 2014
3
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
Client signature
Date
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: info@filt.org.uk
Registered charity number 1103784
July 2014
4