1 2 3 All questions must be answered, unless marked (optional) Free gas safety check - am I eligible?Please fill in this form to apply for your Free Gas Safety Check - to ensure you remain eligible, you'll need to do this once a year.Only submit your application if this is your first request or if your Free Gas Safety Check should be completed within the next 3 months. Have you had a Free Gas Safety Check before? Yes No Date of last free check (optional) Day (optional) Day12345678910111213141516171819202122232425262728293031 Month (optional) MonthJanFebMarAprMayJunJulAugSepOctNovDec Year (optional) Year2017201820192020 Are you supplied by EDF? Yes No In order to qualify for a Free Gas Safety Check you need to be supplied by EDF. Please contact your energy provider to see if you qualify with them. Do you own the property? Yes No In order to qualify for a Free Gas Safety Check you need to be the owner of the property. Please contact the property owner to discuss further details with them. I receive one of the following means-tested benefits: Please select as appropriate (If you do not receive any of the following unfortunately you do not qualify) Income-based Jobseeker’s Allowance Income-related Employment and Support Allowance Income Support Pension Credit (Guaranteed) Tax Credits (Child Tax Credit and Working Tax Credit) Housing Benefit Council Tax Support Universal Credit One of the following applies (if none of the following applies to your situation unfortunately you do not qualify: At least one person living in the house is under 5 years old I am of pensionable age, disabled or chronically sick and live alone I am of pensionable age, disabled or chronically sick and live with others who are all of pensionable age, disabled, chronically sick or under 18 Youngest child's DOB Day (optional) Day12345678910111213141516171819202122232425262728293031 Month (optional) MonthJanFebMarAprMayJunJulAugSepOctNovDec Year (optional) Year201520162017201820192020 Great news, you are eligible for a Free Gas Safety Check. Please click next page to continue with the application.