Agent

Consent form for sharing data with the Energy Saving Trust

We need to check you are eligible for the Energy Company Obligation (ECO4) and/or Great British

Insulation schemes. To do this, we would like to share your information with the Department for

Work and Pensions (DWP) via the Energy Saving Trust who will verify whether or not you are

receiving the relevant benefit(s) to be eligible for either scheme.

Please note that it is not possible for Energy Saving Trust or us, the company using this service, to

see which benefits you are on through this service. DWP will only confirm whether you are in

receipt of a qualifying benefit, not which one. This will not have any impact on future benefit

payments.

If you do not want us to share your data with DWP via Energy Saving Trust, you will be required to

provide copies of documents that provide proof of the benefits you are in receipt of from the

DWP.

For full information on what will happen to the data we collect about you, please see the Privacy

Notice which we will have provided you with separately.

By ticking the box below, and providing your details, you agree to share this data with the DWP

via Energy Saving Trust.

You can contact us to withdraw your consent for us to share your data with DWP via Energy

Saving Trust. If you withdraw consent, the collected data will continue to be processed, however

no new data will be collected or used for further processing.

Occupier / Landlord and Premises Details

The ECO4 and The Great British Insulation Scheme- Templates to evidence private domestic premises and social housing may be used if some evidence is not available. The declaration must be completed and signed by the occupier and the relevant owner, private landlord or the social landlord.

I agree to my information provided (below) being shared with the Department for Work and Pensions via the Energy Saving Trust to confirm whether I am in receipt of the relevant benefit(s) to be eligible for the ECO4 and GBIS schemes.

Yes

Occupant Name

Occupant Email

Occupant Phone

Type of customer

Main applicant

Benefit Recipient

Other

Premises Details

Address Of Installation

Post Code Of Installation

Homeowner OR Landlord Name

Landlord Phone (If Applicable)

Landlord Email (If Applicable)

Occupant EST Signature

Clear

Date EST

Date of birth of Occupier

Benefits Claimed

EPC Rating

Tenure type

Owner Occupied

Private Rented

Social Housing

Type of landlord

Private landlord / managing agent

Social landlord

Name of private landlord / managing agent / social landlord

Social landlord officer name (if applicable):

Social landlord officer job title (if applicable):

private landlord / managing agent / social landlord Phone Number:

private landlord / managing agent / social landlord Email:

private landlord / managing agent / social landlord Full address including postcode:

Occupancy evidence

Proof Of Benefit

Has the PRS Exemption Register Evidence (if applicable) been provided

Yes

Declarations and sign off ( If NOT Home owner skip this step)

i. Landlord Permission and Blended Funding Declaration (to be completed by the private landlord, social landlord officer, or owner-occupier) Funding for measures delivered under ECO4 and the GB Insulation Scheme cannot be blended with funding from other government schemes or grants. Any measures outside of either schemes delivered to the same property would have to be installed either before or after measures are installed . I can confirm I am the (tick below )of the property/properties listed above and hereby give my consent for the works to be completed. I understand I may be contacted by any organisation carrying out the installation works or providing the funding, Ofgem, or an energy supplier, to verify this declaration as confirmation of permission. By signing this declaration, I acknowledge that funding is being claimed through either the Energy Company Obligation (ECO4) scheme or the Great British Insulation Scheme, and I have not and will not seek any funding for such measures through other government schemes or grants. I hereby declare that all the information given above is true and accurate to the best of my knowledge

Type of owner

Homeowner

Landlord

Management Company

ii. Social Housing Declaration (to be completed by the social landlord officer) Social landlord is defined in paragraph 4 of Schedule 1 of the Electricity and Gas (Energy Company Obligation) Order 2022. By signing, I, the social landlord, declare to the best of my knowledge and belief that: I can confirm that the SAP or RdSAP assessment is a true reflection of the property prior to the installation of the measure(s). The premises are let at below market rate, or where the premises are currently void, have previously and will be let at below market rate. I hereby declare that all the information given above is true and accurate to the best of my knowledge.

iii. Data Use Declaration (to be completed by all relevant document signatories)

I hereby declare that all the information given above is true and accurate to the best of my knowledge.

By signing this declaration, I confirm that I have received and read a privacy notice24 to explain how my data will be used, and that this has been shared with all members in the household who may be included or named in documents or information provided in the installation of this energy efficiency measure.

I hereby declare that all the information provided in this form is true and accurate to the best of my knowledge, I confirm this by signing below.

Owner / landlord / social landlord officer signature:

Clear

Owner / landlord / social landlord officer full name:

Date Of Landlord Signature

Child Benefit Self-Declaration

ii. Occupier declaration

I, the occupier of the premises detailed above, declare that I am in receipt of Child Benefit, and that for the corresponding number of qualifying children or young persons within this benefit, the threshold for single or combined annual gross income (from all sources) detailed in the table overleaf is not breached.

I confirm that the information provided in this declaration is true and accurate

Child Benefit Number

If no CHB, please provide National Insurance number:

Child Benefit Signature

Clear

I, the relevant third party, declare that, to the best of my knowledge, the person living at this premises detailed above is in receipt of Child Benefit; and is not in receipt of any of the other qualifying benefits listed in schedule 2 of the Electricity and Gas (Energy Company Obligation) Order 2022

CB Third Party Name

Organisation