Consent Form for Data Sharing – Green Eligibility

To check your eligibility for our Energy Support Scheme, we (Green Eligibility) may need to share your information with the Department for Work and Pensions (DWP).

By completing this form and giving consent, you permit us to share your data with the DWP.

I agree that my personal information may be shared with the Department for Work and Pensions via Green Eligibility for benefit eligibility verification.

Customer Details

Title MrMrsMissMsOther First Name Surname Date of Birth Type of Customer Main applicantBenefit recipientOther If Other, please specify

Full Address Details

House Number / Street Town / City County Postcode Telephone Number Email Address

Preferred Contact Method

TelephoneEmail

Consent Confirmation

Signature (type your full name) Date