Options form (pdf 389kb) - Switchover Help Scheme

Resident details:
Title: Mr Mrs Miss Ms Date of birth
First name
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
First name
No (Please put a cross).
nX
n X
Resident details:
Title: Mr Mrs Miss Ms Date of birth
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
First name
No (Please put a cross).
nX
n X
Resident details:
Title: Mr Mrs Miss Ms Date of birth
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
No (Please put a cross).
nX
n X
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nnnnnnnnnn
nnnnnnnnnn
nnnnnnnnnn