Eligibility check

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e.g. mortgage/rent, gas, electric or water?

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e.g. Income Support, Income-based Job Seekers Allowance, Income-related Employment Support Allowance, Universal Credit, Housing Benefit, Working Tax Credit, Child Tax Credit (excluding receipt of the family element only) or Pension Credit

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e.g. Desquamation, weeping skin disease, incontinence, abdominal stome, Crohn’s’s disease, Ulcerative colitis, Renal failure requiring home dialysis or any other medical condition that uses significant volumes of water and can be support by a doctor’s certificate?

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include Household averages our area

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This includes any charges from Anglian Water you receive from Affinity Water or Hartlepool Water

  • Customer account number (on the front of your bill)
  • Valid email address
  • Address details
  • Housing costs
  • Benefits received (amount) (if applicable)
  • Income received (amount) (if applicable)

All fields marked with (*) are mandatory

01 - Personal details
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About You

Personal details

Contact Details

Personal assistance

What is their relationship to you?

(For example, they could be a friend, family member, or social worker)

Housing

Housing details

How many people live at your property?

Please provide the Date of Birth of child

Housing costs

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Income & payments

Income

(Please deduct any child maintenance commitments you have at this stage)

£
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£

Benefits

£
£
£
£
£
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Arrears support

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Confirmation check

Thanks for completing our Extra Care Assessment.

We’ll be in touch within 7 working days to confirm the outcome of your assessment.