Self declaration form - Watersure | Get in touch

{panel-id} About you

The asterisk (*) symbol denotes required fields.

Account number: *

Please enter a valid account number:

Full name: *

Please enter a valid full name:

Email *

Please enter a valid email

{panel-id} Benefits

The asterisk (*) symbol denotes required fields.

Are you, or a member of the household in receipt of any of the following benefits? Please tick all that apply *

Please select an option

Are you, or a member of the household in receipt of DLA or PIP? Please tick the box that applies *

Please select an option

If you have selected "None of the above" and are no longer receiving eligible benefits, we will update your account accordingly and remove you from the scheme on receipt of your self declaration.

{panel-id} Medical conditions

The asterisk (*) symbol denotes required fields.

Complete this section if you receive WaterSure due to a medical condition.

If you receive WaterSure for three children or more under the age of 19, continue to the next section.

As your WaterSure application includes information about your medical condition, we need your consent to process your application. I consent to my medical information being processed

Please select an option

Do you, or a member of the household have a medical condition which requires the use of additional water?

Please select an option

{panel-id} Children under 19

The asterisk (*) symbol denotes required fields.

Complete this section if you receive WaterSure for three or more children under the age of 19.

If you receive WaterSure due to a medical condition, please make sure you have completed the previous section.

Tick this box if there are 3 or more children in the household under 19 years of age for which you receive child benefit

Please select an option

{panel-id} Confirmation of circumstances

The asterisk (*) symbol denotes required fields.

Please select the one which applies to your current circumstances.

I confirm that my circumstances haven’t changed and I am still eligible for the WaterSure scheme. I agree that I will provide proof I still qualify for the scheme if asked. If I cannot provide this I will be taken off the scheme and I will receive a standard bill

Please select an option

OR

I confirm that my circumstances have changed and that I am no longer eligible for the WaterSure Scheme. I understand that my future water bills will no longer be capped and will be charged at the standard applicable rates.

Please select an option

{panel-id} Consent

The asterisk (*) symbol denotes required fields.

Please tick the box if: *

Please select an option

Please tick the box if:

Please select an option

If you are not currently paying on a payment plan, we will automatically set a monthly Watercard payment plan for you to help spread the cost of our water bill.

Please check you have completed all the sections that are true and reflect your circumstances before you submit the form.

Internal form number: WS001