To qualify for WaterSure someone in your household must be receiving at least one of the benefits or tax credits listed above. Please note that you must submit a copy of the latest notice of entitlement for the benefits or tax credits and this notice must be less than a one-year-old.

Please note that bank statements are not accepted as proof of Employment Support Allowance or Jobseeker’s Allowance.

Please provide all known information of the medical practitioner who can confirm this medical condition(s).

Important

Evidence required for medical conditions

A copy of your repeat prescription for each condition that you have ticked is required.

We can accept a doctor’s certificate explaining the condition and why extra water is needed.

You can ask for copies of these from your surgery, clinic, or hospital.

If you do not have a certificate or prescription, you will need to provide us with evidence that you have the condition and why extra water is needed.

If you tick ‘other condition’ you will need to provide a doctor’s certificate or letter from a GP or hospital consultant. The certificate or letter needs to include:

• The name of the patient
• The condition they have which means that they use extra water
• The date the certificate or letter was issued, and the name position and address of the GP or consultant.

Important

Evidence required for 3 or more young children

Please provide the full name and date of birth for each child. You must provide a copy of the latest notice of entitlement to Child Benefit for each child you list here.

Alternatively, you can provide a copy of a recent bank statement listing your current entitlement to payments.

If you cannot find your notice of entitlement to Child Benefit, please contact the Child Benefit Centre.

The information I have given is correct to the best of my knowledge and I understand that, if I provide any information which is false, you may refuse to consider my application.

If my circumstances change, and it may affect my application, I will tell you straight away.

I authorise my benefit providers to give LM Water any relevant information to confirm the details I’ve provided.

If I have made a claim because of a medical condition, I give the medical professional who knows about the condition, permission to give LM Water information about the condition and why I need to use more water.

If I pay my wastewater charges to a different company, I give you permission to pass on the details provided so that a reduction can also be made to my wastewater charges under the WaterSure tariff.

If you deliberately give LM Water misleading information you are committing a criminal offence and could be prosecuted.

I confirm the following:

• A member of my household meets the conditions for help under the WaterSure Scheme.
• I only use a hosepipe or watering can to water my garden.
• My household does not have an auto-filling swimming pool or pond which holds over 10,000 litres of water.
• I do not receive any help towards the cost of water from the health authority.