1energy – Fortis Advisory CIC

Energy Top-up request

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

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

Choose File

Photo of balance on meter (criteria: will run out within 48 hours)

Choose File

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

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.