Self declaration form - Watersure | Get in touch

The asterisk (*) symbol denotes required fields.

About you

Account number: *

Please enter a valid account number:

Full name: *

Please enter a valid full name:

Email *

Please enter a valid email

Benefit

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

Please select a title

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

Please select a title

Medical

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 a title

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

Please select a title

Family

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 a title

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 bill *

Please select a title

Please tick the box if: *

Please select a title

Please tick the box if:

Please select a title

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