Please enable JavaScript in your browser to complete this form.Do you have a pre-payment meter? *Please choose...YesNoThis scheme is only available to energy customers with prepayment meters.NamePlease choose...MsMrsMrDr.Prof.Rev.Date of birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodePhone number *Please tick which ways you are happy for us to contact you by. *PhoneVoicemailTextEmailLetterPlease tick as many as possible to make it easier for us to support you.Email *EmailConfirm EmailPlease tell us a little bit about your householdPlease tick the statements that apply to youI live alone.Other than myself, there is at least one person over 18 living in my household.There is at least one person under 18 living in my household.How many dependents between 13 - 17 years old live in your household?How many dependents between 0 - 12 years old live in your household?Your energy detailsDo you top up your prepayment meter by either smartcard or key? *Please choose...YesNoPlease enter your card number or key number to allow your voucher to be attached to your account. *This avoids your voucher being used by another personDoes British Gas supply either your gas or electricity? *Please chooseYesNoHow would you like to receive your fuel top up voucher? *Please choose...LetterEmailHow have you been affected by Covid-19? *Employment issues (lost job, furloughed, made redundant...)Reduced income (loss of job, reduced hours...)Increased bills (food, utilities...)Childcare issues Mental health issues (stress, anxiety, depression)Physical health issues (new condition or worsening of existent condition)Family or relationship issuesDiscrimination issues (age, race, gender, religion...)Data protection *I agree to Citizens Advice - Bath & North East Somerset storing and using information about meWe keep your details on our database which is confidential to Citizens Advice. The details we take are to enable us to give you the appropriate advice. They aren’t accessed by anyone else except in the case of gathering feedback on our service which is also done confidentially. We don’t sell your data to anyone. Submit
