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WaterSure Scheme

APPLICATION FORM
We understand that paying bills can be a worry, particularly for households with low incomes.

WaterSure is just one of the ways we can help make things easier, by capping eligible customers’ bills
Who is eligible?
WaterSure only applies to customers who have a

water meter. You, or someone in your household, must be receiving one of the following:

• Income-related Employment and Support Allowance or Income Support

• Income-based Jobseeker’s Allowance

• Housing Benefit

• Pension Credit

• Working Tax Credit

• Child Tax Credit

(other than just the family element)

• Universal Credit



At least one of the following must also apply:
• Three or more children under the age of 19 living in the household, and you (or the person responsible for them) claim Child Benefit for them; or

• You or someone living in your household has a medical condition that means they use a lot of extra water.
How to apply
If you think you’re eligible for WaterSure, complete

this form and we’ll do the rest.

Fill in this application form and return it to us with the necessary supporting evidence in the envelope provided.

The person named on the water bill must sign this form. If the person who receives the benefit is not the bill payer, please include their signature too, in case we need to contact Jobcentre Plus for more information.

We will aim to give you a decision within five working days. We’ll contact you if we need any more information.

If your application is not successful, we’ll tell you why.

If your application is successful, we’ll apply the changes to your next bill.
Do you need help with this form?
Call our special helpline 0333 3208 656 lines are

open Monday to Friday 9am to 4pm

Please call for more details or visit https://www.countywater.co.uk/
Please note

Under the WaterSure Scheme, your charges will be capped at the average metered bill rate. This will vary slightly each year as average bills change.
If your actual bill is lower than the cap we will just charge you the lower amount.
1. About you
1.Name and Surname
2.Road Name
3.Date of Birth
4.Your Email
5.Your Phone number
6.County Water account number (you can find this on your sewerage bill)
7.Are you, or anyone in your household, receiving any of the following benefits or tax credits? (please tick all that apply)
1. Please give the name(s) and National Insurance number(s) of the person who receives one or more of the above benefits or tax credits.
8.Name
9.National Insurance Number
10.Name
11.National Insurance Number
12.Name
13.National Insurance Number
Notes

To qualify for WaterSure someone in your household must be receiving at least one of the benefits or tax credits listed. You must provide a photocopy of the latest notice of entitlement for the benefits or tax credits. The notice of entitlement must be less than one year old.

If you are applying for WaterSure based on a medical condition, please fill in section two. If you are applying based on the size of your family, go straight to section three.

If you do not have a notice you can get a replacement by contacting your local benefit or tax office or send in a bank statement (no older than three months) clearly showing the benefit. Please note, bank statements are not accepted as proof of Employment Support Allowance or Jobseeker’s Allowance
2. Medical conditions (where appropriate)
We need to know the name of the person with the medical condition
14.Please tell us the name of the person in your household who has a medical condition that means they have to use a lot of extra water
Please tell us the medical conditions the person has by ticking all the relevant boxes. Important – if you tick one of the named conditions listed, please give us a copy of your repeat prescription form or doctor’s certificate explaining your condition and why you need to use extra water. You can ask for copies of these from your surgery, clinic or hospital. If you don’t have the prescription or certificate, please provide some other evidence that you have the condition and why you need to use extra water. Or, if you tick ‘Another condition’ you must include a doctor’s certificate or letter from a GP or hospital consultant. The certificate or letter must say:

The name of the patient

The condition they have which means they have to use a lot of extra water

The date the certificate or letter was issued And

The name, position and address of the GP or consultant.
15.Which of these medical conditions do they have? (tick all that apply)
16.Please tell us the name of this condition
Please tell us who we can contact to confirm this condition (for example, a doctor or hospital consultant).
17.Please give the name and address of the doctor or hospital consultant who knows about this condition
18.Address and postcode
19.Phone number
20.Surgery or health centre official stamp (optional)
We recommend you also register for our Priority Services (see part 6)
3. Your family (where your application is because you have a large family)
This section is for families with three or more children under 19 living at home
21.I confirm that I, or a member of my household, receives benefits or tax credits (named at question 10) and Child Benefit is claimed for three or more children under 19 who live with us permanently
Please give the full names and dates of birth of these children (continue on a separate sheet if necessary)
Please provide the full name and date of birth for each child. You must provide a copy of the latest notice of entitlement to Child Benefit for each child you list here. Alternatively you can provide a copy of a recent bank statement listing your current entitlement to payments. If you cannot find your notice of entitlement to Child Benefit, please contact the Child Benefit Centre.
22.Name
23.Date of birth (DD/MM/YY)
24.Name
25.Date of birth (DD/MM/YY)
26.Name
27.Date of birth (DD/MM/YY)
28.Name
29.Date of birth (DD/MM/YY)
4. Important supporting documents
Checklist
30.Checklist
I confirm the following:

• A member of my household meets the conditions for help under the WaterSure scheme.

• I only use a hosepipe or watering can to water my garden.

• My household does not have an auto-filling swimming pool or pond which holds over 10,000 litres of water.

I do not receive any help towards the cost of water from the health authority
31.Account holder signature
32.Date
33.Signature of the person(s) receiving benefit (if different from above)
5. Declaration
The information I have given is correct to the best of my knowledge and I understand that, if I provide any information which is false, you may refuse to consider my application.

If my circumstances change, and it may affect my application, I will tell you straight away.

I authorise my benefit providers to give Thames Water any relevant information to confirm the details I’ve supplied.

If I have made a claim because of a medical condition, I give the medical professional who knows about the condition permission to give you information about the condition and why I need to use more water.

If I pay my wastewater charges to a different company, I give you permission to pass on the details provided so that a reduction can also be made to my wastewater charges under the WaterSure tariff.

If you deliberately give us misleading information you are committing a criminal offence and could be prosecuted.
6. Priority help if there’s a problem with your sewerage
34.We offer a range of support for people who need it if there’s a problem with your supply.

You can register online at