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Self declaration form - Watersure

The asterisk (*) symbol denotes required fields.

Letting us know you’re still eligible for the scheme, you’re saying that your circumstances haven’t changed and you’ll continue to benefit from capped water bills.

If you let us know you're no longer eligible for the scheme future bills will be based on the amount of water you use. If we don’t receive the ‘self declaration form’ back, we’ll assume you are no longer eligible & remove you from the scheme, a new application will have to be submitted to get back onto the scheme.

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

Is your medical condition likely to affect you for the rest of your life? *

Please select a title

We want to make things as easy as possible for you. Usually, we need you to reconfirm you're still eligible for the scheme every year. However, if you have a lifelong medical condition then we'll only ask you confirm you're still in receipt of a qualifying benefit, and only every 5 years instead of 1.

If you've ticked Yes, we'll need you to provide evidence, to prove that you have a lifelong medical condition. This evidence can be a letter from your doctor or consultant to say that your condition will likely affect you for the rest of your life.

Once we have this, we won't ask you to give us this again. We'll just check in with you every 5 years to confirm that you're still in receipt of a qualifying benefit.

Attach documents

Select File Please upload a file

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

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

Internal form number: WS001