2energy – Fortis Advisory CIC

70+ Energy Top-up request

Is your age 70 or over?

Yes

No

Please complete the energy topup form for those under 70

Do you have a prepayment meter?

Yes

No

Sorry, energy help is only available through Prepayment Meter vouchers

Title

First Name

Last Name

Date of Birth

Address

Address Line 1

Address Line 2

City

Post Code

Email

Phone/Mobile

Energy details

Select what you have

Electricity and Gas (same supplier)

Electricity and Gas (different suppliers)

Electricity only

Energy Supplier

Energy Supplier – Electricity

Energy Supplier – Gas

Where can you top up?

PayPoint

Post Office

How would you like to receive the energy voucher?

By text message

By Email

Do you have a smart meter?

Yes

No

Unknown

Brief description of your circumstances – why you are struggling to top up

Household details

Number of adults in property

1

2

3

4

5+

How many of these adults are 66+

0

1

2

3+

Number of children in property

0

1

2

3

4

5+

Evidence

Are you able to provide proof of low bank balance?

Yes

No

Photo proof of name and address (letter, drivers licence etc)

Choose File

Photo proof of low bank balance (does not need to be £0)

Choose File

Proof of name and address (letter)

Choose File

Proof of age (drivers licence, passport, birth certificate, other)

Choose File

I confirm that I cannot afford to top up my energy meter and it has either ran out, or will run out within 48 hours.