Please enable JavaScript in your browser to complete this form.Why are you contacting us? *Please choose…I'm seeking help for a clientI'm seeking help for myselfWe are sorry but this fund has now been fully allocated.You may be eligible for support with fuel costs via BANES Welfare Support. It can be accessed via the BANES web site: https://beta.bathnes.gov.uk/apply-welfare-supportWhat is the name of your organisation? *What is your name? *FirstLastWhat is your email? *EmailConfirm EmailDoes your client prepay for fuel? *Please select one optionYesNoHow do they prepay for fuel? *Please select one optionKeyBanking appWhat is your phone number? *Who is their current supplier? *How do they pay for their supply? *Please choose…Direct debitPre-payment AppKeyPrepayment meterQuarterly billsSmart meter/appWhat is your client's first name? *What is your client's last name? *What is your client's date of birth? *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is your client's address? *Address Line 1Address Line 2CityState / Province / RegionPostal CodeIs your client capable of receiving emails and text messages? *Please select one optionYesNoPlease tick which ways your client is happy for us to contact them by. *PhoneVoicemailTextEmailLetterPlease tick as many as possible to make it easier for us to support them.What is your client's phone number? *What is your client's email? *EmailConfirm EmailWhat is their fuel account number? *Please tell us a little bit about the householdWhat is their housing status? *Please choose…OwnedRented privateRented social housingOther (Please specify)Housing status *How many are adults; 18 years old and above? *How many are dependents; between 13 – 17 years old? *How many are dependents between 0 – 12 years old? *What is the combined household income each month? *Please include all forms of income linked to each member of the household; such as wages, Universal Credit, money from self-employment, Tax Credit, Job Seeker’s Allowance (JSA), Employment and Support Allowance (ESA), Personal Independence Payments (PIP), Disability Living Allowance (DLA).How much does your client spend on heating and electricity each month? *Data protection *By ticking this, your client agrees to Citizens Advice – Bath & North East Somerset storing and using information about them and consents to being contacted by the charity.We keep client details on our database which is confidential to Citizens Advice. The details we take are to enable us to give 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 client data to anyone. Submit