Self declaration form - Watersure | Get in touch

Self declaration form - Watersure

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 value

Full name: *

Please enter a valid value

Email *

Please enter a valid value

Benefit

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

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 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

Family

Tick this box if there are 3 or more children in the household under 19 years of age

Please agree to our terms and conditions

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 agree to our terms and conditions

Please tick the box if: *

Please select an option

Please tick the box if:

Please select an option

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

Internal form number: WS001